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STATE OF NEBRASKA 2 QHQ 9 6 8 8
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND;HUMAmV gRVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE'NEBRASKA; bEEPARTWMVT,6RI~EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VfT3A4 )ftORDS - I
<br />DATE OF ISSUANCE
<br />S4 _
<br />qqp~lyy e . G rrd
<br />DEC b~NLEY S . QOPER rr rx
<br />ASSVVA 1R" 9b E,#,EG~S7rRAkr r v
<br />DEPARTMENT 1 /~x AAU)'
<br />LINCOLN NEBRASKA HUMAN SERVICES : . ' a
<br />I
<br />STATE OF NEBRASKA-DWAFITMENTOFHEALTH ANDHUMAN SEFIVICESFINANCEAPIDSUPPOF~IIQ 212-63
<br />rr-RT10BI wrr. no nnaTW U J
<br />1.DECEDENT'8- l (First, Middle, Lest. suffix)
<br />2. SEX
<br />3. DATE OFDEATH (Mo.,Day,Yr.)
<br />Maxie Wilke
<br />Female
<br />February 11, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH es. AGE-Leal Blr%day Bb. UNDER 1 YEAR
<br />80. UNDER 1 DAY
<br />B. DATE OP BIRTH (Mo., Day, Yr.)
<br />(Ym.)
<br />MOB.
<br />DAYS
<br />HOURS
<br />MINE.
<br />Hall Co=ty, Nebraska
<br />82
<br />December 27, 1926
<br />' 7.80ClAL1IECURITY1'IUMBER
<br />BLPLACEOFOEATH
<br />09_ 29-0620
<br />~d
<br />yQ3PRAL 0lnpe2om Ma ANurelnpNameRTC.OHospiosFaaOBy
<br />8b. PACILITY-NAME (If not Inst(tudon, viva street and number)
<br />;O G] decWent's
<br />Gold km Living Center ~ Park Place
<br />O Doc (3 CgIm(SpeaBy)
<br />BeCITYOHTOWNOPDEATH (Induderpoods)
<br />B&COUNTYGFDEATH
<br />Grand island 68803
<br />Hall
<br />BaREB21E0-STATE
<br />&COUN Y
<br />9o CIIYORTOWN
<br />Nebraska
<br />Grand Island
<br />-
<br />.I IDEd0LIMITS
<br />s6BTRWANDNUA®ER go. APT. NO W.ZIPCODE Fig
<br />224'11 Emby 1 .1 68803 61 YES Q No
<br />10a. MARITAL STATUS ATTIME OF.DEATH X Merried O Never Mauled 10b. NNE OF SPOUSE (First. Noddle, Last. Suffix) U wife, give maldsn name.
<br />0Married. tiutseparated Owidened ODtromed OUntomrrn Lyle Wayne Wilke
<br />it. FATHER'S-NAME (First, Middle, Lsst, suffix)
<br />12. MOTHERS-NAME (First, Middle, Maiden Surname)
<br />William Rerman Pahl
<br />Marie Irene Mathews
<br />13. EVER IN U.B. ARMED FORCES? Give dates of eervloe If yea.
<br />14s. INFORMANT NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />(rea no. o< ) (xo)
<br />L le Wayne Wilke
<br />Husband
<br />IL METHODOFOISPOSITION
<br />18a.EMBAMIEjR411GNATURE
<br />18b.UCENSENO.
<br />ifio. DATE (Mo., Day, Yr.)
<br />OBudal. ODormtlon
<br />rebroary 12 2009
<br />SCremation OEnmmbmsm
<br />-
<br />18d.CEMETERY,CREMATORYOROTHER LOCA71ON CITY/TOWN STATE
<br />QRemovsl OOlher(SpeoBy)
<br />Central Nebrasks Cremation' Service, Gibbon, Nebraska
<br />17L FUNERAL HOME NAME AND MAILING ADDRESS (Stme , Ogy orTown, 8tete) 17b. Zip Code
<br />Klei:ie raneral Rome 3213 W North Front St. Grand Island, N13 -68803
<br />1a FART L Enter the Injudea,orcomplloatloae-thetbectly the desk DO NOT order temdrrelevents ambasalydieaertea4 I APPRUMATEINTERVAL
<br />resphat umAorventri Wwfilu➢Iaiamw2hmdVmwlgt esilologDONOTABBREVNTE.Enteronly oneoauaeonaOnAddedif lonalam11neoastiM.. i
<br />IMMEDWTECAUSE I onset to death
<br />SdMEDIATBCAIls38(Piml 0) • I 0 S
<br />dbassoraoaftort 111 p DUEAO GRASACONSEQUENCEOF I onsel to death
<br />Ind4~1) , ' ' I
<br />BegeadLBytlsteottlAtlan B (b) /tQ /Q
<br />.o -Iasdlellimtl taws Sled DUE TO, OR A NSE0 CE OP. onsatto
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<br />Off ftutlDERLYB1GlJdg78
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<br />Sei-ft lb self DUE .ORABACONSEQUENCEOF:' I I orusatto
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<br />18. PART R. OTHERSIGNIFICANTCONDITION84uttlihnsete bu►blpathedealbbuhmtresultingin theundedyingoaaesgWinPART 1. 15 WASMEWCALUAMQIER
<br />OR CORONER CONTACTED?
<br />' q.- O YES NO
<br />0
<br />. IFFEMALE
<br />2
<br />21a.ONWNi409FDEATH
<br />21b.IFTRANBPORTMONDIJURY
<br />21o,WASANAUTOPSY PERFORMED?
<br />~
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<br />,
<br />LsaPre2rmMwwghhlPealYear
<br />talr
<br />SNalarel OHorwows
<br />OOdvadOparamr
<br />OYES ~0
<br />.
<br />OPeeeerl
<br />er
<br />O Pre
<br />nantatUmeofdeath
<br />O'Ao KWE3Pen&V nveeBOaOon
<br />p
<br />2
<br />Ot101pregnarlLbulpreg>mnlwithln42daysofdea8,
<br />OSuloide OCoWdlrolbedmermmM
<br />OPedesiden
<br />21cLWEREAUTGPSYFOINGSAVNL4]LETO
<br />(3 Natpregllml6 but prepnem4sdnyelD, yeerlwfinetleam
<br />1130ther(Spea6y)
<br />c;oNPLarecausEOp DEIDII4
<br />b Unkilan0pregnontwWAthepastym
<br />O YES O NO
<br />22a. DATE OF INJURY (Ma, Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />220. PLACE OF INJURY-At home, farm, shsel, faa", office building, conadlmpon ob, WA (Bpsclfy)
<br />71dDIJURYATWORK?
<br />-
<br />22eCERISE NOWINJURY OCCURRED
<br />O YES QN0 -
<br />- - -
<br />22LLOCATIONOFINJURY -STREET&NUMBER, APT.NO, Lg1Y/rom > ZIPCODE
<br />i
<br />239.DATEOFDEATH WOey,Yr.) 94e.DATEMNED (Mo.,Day,Yr.) 24bTIME OF DEATH
<br />M
<br />AIA
<br />23h DATBBidNE6 Ma, Day,Yr.) 23o.TIMEOFDEATH 1 24c. PRONOUNCED DEAD (M0.Day,Yr.) 24d.101EPROr101WCEDDEAD
<br />;A0, m. 1 m
<br />date .Ph 24s.onowbealsofwilthlaionm /orWastilsi t,MoryoplnlondaMoooutredat
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<br />8 the dons, do and pleas and due to tha cause(s) stated. (SIP MM Ged Title) •
<br />2tLnmTOBA000USE00NTRIB TOTHEDEATH? 28a.K48ORGAN ORTISSUEDONATION BEEN CONSIDERED?
<br />2MWA; CONSENT GRANTED?
<br />O YES VNO O BABLY O UNKNOWN O Y S 19.110
<br />Not Appllceble g 28e is NO DYES ONO
<br />ADDREP CPCERTIFIER ICIMCOROQIERB ICWNOR ATTO En ftpeorPring
<br />L pAK/C7GC IALft(p xW1
<br />28aRCir1 (IrWTURE
<br />20b.DATE FIEDBYREOISTRARNo.,Day,Yr.)
<br />
<br />.
<br />FEB 11 2009
<br />HH"l11 /03(65061)
<br />
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