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STATE OF NEBRASKA iG 01 MG 8 d WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPA tkr QF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR .VITAL RFEORt'I ^ " ' DATE OF ISSUANCE a ` STAME'Y S: ;CR. APEJ2 a 12/20/2011 ASSIjt4jNT ATg T' RA Z DEPARTMEN ' pF iEALT~1 ANb LINCOLN, NEBRASKA HUMA* SER 1C: STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES, 1,10$159 CERTIFICATE OF DEATH 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX pDATE OF OF ATH (M, , Day, Yr.) e Lyle Wayne Wilke Male Septbmbe 20, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE-bF 61RTH (Mo., Day, Yr.) (Ym•) MOS. DAYS HOURS MINE. Shelton, Nebraska 84 February 26, 1927 71 SOCIAL SECURITY NUMBER 1 8a. PLACE OF DEATH 508-30-3372 HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY-NAME (If not Institution, give street and number) ❑ ER/Outpatient ® Decedents Home 224 North Ruby ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) COUNTY OF DEATH r- o Grand Island 68803 Hall go. RESIDENCE-STATE 9b. COUNTY -7 . CITY OR TOWN - w Nebraska Hall Grand Island M 90. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 8g. INSIDE CITY LIMITS 224 North Ruby 68803 ® YES ❑ NO 108. MARITAL STATUS AT TIME OF DEATH[] Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) N wife, give maiden name ❑ Married, but separated M Widowed ❑ Divorced ❑ Unknown Leola M Pahl 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname) Harry Wilke Dortha Dora Bowen E 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT 8 (Yes, No, or Unk.) No Stanley A Wilke Son ,a 15. METHOD OF DISPOSITION 18a. EMBALMER-SIGNATURE 18b. LICENSE NO. 18x. GATE (Mo ,Day, Yr.) H ❑ Burial ❑ Donation Not Embalmed September 23, 2011 ® Cremation ❑ Entombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE ❑ Removal ❑ Other (Specify) Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code Kleine Funeral Home, 3213 W. North Front Street, Grand Island, Nebraska 68803 CAUSE OF DEATH See Instructions and examples) It PART 1. Enter the chain of events,-diseases, injuries, or compticatima-that directly caused the death. DO NOT enter terminal events such as cardiac street, ; APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without shaming the etiology. DO NOT ABBREVIATE. Enter only one cause on a titre. Add additional lines H necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Heart Failure ; Immediate disease or condition resulting i in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially Ilst conditions, I b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE C) ; (disease or Injury that inithdad the events resorting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST 18. PART [.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO LL 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Not pregnant within past year ® Natural ❑ Homicide ❑ Driver/operetor ❑ YES ® NO ❑ Pregnant at time of death ❑ Accident ❑ Pending investigation ❑ Passenger ❑ Not pregnant, but pregnant within 42 days of death ❑ Suicide El Could not be determined [3 Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE E CAUSE OF DEATH? OM LE ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Other (Specly) TO C P T ❑ Unknown if pregnant within the past year ❑ YES ❑ NO E 228. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction sae, etc. (Specify) 8 2 22d. INJURY AT WORK? 220. DESCRIBE HOW INJURY OCCURRED F ❑ YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APTAO. CITYITOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) k 24a. DATE SIGNED (Mo., Day; Yr.) September 22, 2011 24b. TIME OF DEATH Approx. 05:00 PM 23b. DATE SIGNED (Mo., Day, Yr.) 23x. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD Z September 20, 2011 06:52 PM 8 M. To the beat of my knowledge, death occurred at the time, date and place and due to the cause(s) stated (Signature and Title) O 2 49. On the bests of examination and/or investigation, in my opinion death occurred at the time, data and place and due to the cause(s) at". (Signature and TWO) v O ~ ' s Robert Cashoill, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO Not Applicable H 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS F CERTITIW(PHYSICIAR, PHYSICIAN ASSISTANT, CORO ER PHYSICIAN OR COUNTY ATTORNEY) (Typo or Print) Robert Cashoili, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 4 28a. REGISTRAR'S SIGNATURE 1 7 DATE FILED BY REGISTRAR (Mo., Day, Yr.) ~ ' - 40 27, 2011 September