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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY GARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF I
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEt
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQ
<br />DATE OF IS5UANCE ; /�
<br />01/19/2012 201244��� :' �5
<br />�
<br />LINCOLAI, NEBRASKA �C�,
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HU�N�'SEI
<br />CERTIFICATE OF DEATH ', � � ��
<br />:CEDENTS-NAME fFtrat Mlddle. Last SuHirzl , ,'� 2:6'
<br />Shickley, Nebraska
<br />SOCIAL 8ECURITY NUMBER
<br />505-26-3236
<br />OF BIRTH 5a. AGE - Last Birthday b. UNDER 7 YEAR
<br />(Y►$d MOS. DAYS
<br />91
<br />PLACE OF DEATH
<br />Grand Island Veterans Home
<br />, CITY OR TOWN OF DEATH (Include Zlp C�e)
<br />Grand Island 68803
<br />VICES, IT CERTIFIES
<br />HEAlTH AND
<br />�11.r -
<br />�
<br />raa
<br />iV`�E�ZGICE�"
<br />i ' k.
<br />�z �:;ff w � � i �" i ':� :1.1; 04458
<br />�
<br />'; 3. DATE OF (MO., Day, Yr.)
<br />le �.' i � Decarnber 30. 2011
<br />' -� - ' � Au9ust 20; 1920
<br />�.
<br />HOSPRAL � I�atlerU OTHER � Nursl� Home/LTC � Hospice Fac11Hy
<br />p Ewo�e.�c p o�a.�r$ Ho�
<br />❑ DOA ❑ Other (SPecffy
<br />ed. couNrr oF neo,ni
<br />Hall
<br />i. RESIDENCE-STATE 9b. COUNTY 8c. CITY OR TOWN
<br />Nebraska Hatl Grand Island
<br />I. STREET AND NUMBER . APT. NO. 8L ZIP CODE 9g. INSIDE CITY lIM1T9
<br />620 N Grace Ave 68803 � ves ❑ No
<br />la. NWRITAL STATUS AT TIME OF DEATH � AAarrted � Never Manled 10b. NAME OF SPOUSE (Flrsf, Middte, Last, Suftbc) H wBe, give maiden rrame
<br />p n�mea, a� $e��cea p wwo,�ea ❑ on�o�a p u�now� Jack A Hann
<br />I. FATHER'S-NAME (First, Middle, Last, Suftbc) 12. MOTHER'S-NAME (Fl�st, Middle, Mlaiden Sumame)
<br />Walter G Dodge Eva C Porlwood
<br />I. EVER IN U.S. ARMED FORCES? Gfve dates oi aervlce H Y�. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />nes, No, or unk.) No Jack A Hann Husband
<br />i. METHOD OF DISPOSff10N 18a. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />❑ Burial ❑ oonauon Not Embalmed December 31, 2011
<br />� CremaUon ❑ EntombmerK 16d. CEMETERY, CRENWTORY OR OTHER LOCATION CITY I TOWN STATE
<br />❑ Removal ❑ Other ISP�KY)
<br />Central Nebraska CremaUon Services Gibbon Nebraska
<br />'a. FUNERAL HOME NAME ANp MAIUNG ADDRESS (Street, Cityr or Town, State) 7Tb. Zip Code
<br />Kleine Funeral Home, 3213 W. North Front Street, Grand Island, Nebraska 68803
<br />IB. PpRT L EMaz Ure chain nf eve�•-0leeases, InJurlea, or complieadons4hat directiy eaused Ure death. DO NOT errtertemdnal eveMS euch es cardiae arrest,
<br />respUatory erteat, or veMrieular flbrliladon atthout showing the eUology. DO NOT ABBREVWTE Emer only o�re eause on e Ihre. Atld adtlitlonal p� If �.
<br />IMMEDIATE CAUSE:
<br />n�Meou►� cause ��i al Vascular Dementla
<br />disease or eondiHOn resuRing
<br />1° tl � ' � DUE TO, OR AS A CONSEQUENCE OF: �
<br />SbqueMlaliy Iist corulitlone. H b)
<br />anY. leading to the cause Ilstad
<br />on 11�re a pVE TO, OR AS A CONSEQUENCE OF:
<br />E,iRer Gre UNDERLYINO CAUSE C �
<br />(dlaease or Inlury tnat �nidateA
<br />Ure e"8"m remdtl"g m ae�l'� DUE TO, OR AS A CONSEQUENCE OF:
<br />� d)
<br />STATE
<br />1: PART IL OTHER SIGNIFlCANT CONDff10NSCo�klorm coMributing to the death but not resulU� In the uMerying cause phen In PART b 78. WAS MEDICAL EXAMINER
<br />Generalized Atherosclerosis, Presbyesophagus oR CORONER CONTACTeo7
<br />❑ rES � No
<br />I. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21e. WAS AN AUTOPSY PERFORMED?
<br />� Not pregnant rrtthin pant year � n�e��i � Homldde 0 on�ror+��co. �
<br />Q PreBnarrt et tlme oi death � Axitlwrt � Pendin9lnveatl8adon ❑ P�^98� ❑ YES � NO
<br />� NoS prepnant, but pregnarrt �rithln 42 days of death � pedestrtan 27d. WERE AUTOPSY FlNOINGS AYAILA
<br />� sulWae � coWd �ros be aemrmi�rea TO COMPLETE CAUSE OF DEATH?
<br />� NM P�B�. but pre8nant 49 days to 1 year before deeth � Other (SPBCIh) � YES ❑ NO
<br />Q UNmown H PreBnant within thB Paet Year
<br />ta. DATE OF INJURY (Mo., Day, Yr.) 92b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, taetory, office buildl�, w�retructlon site, ete. (SpeW(y)
<br />❑ YES ❑ NO I
<br />f. LOCATION OF INJURY - STREET 8� NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />� December 30, 2011
<br />� � 23b. DATE SIGNED (IVIo., Day, Yr.) 23c. TIME OF DEATH
<br />Z December 30, 2011 04:30 AM
<br />� � To tlre best af my Imowtedp& deafh oec�ured at the tivre. date mM Place
<br />� artd due to the muse�s) atated. (Signatwe and T(tie)
<br />Gene L. Wyse, DO
<br />APPROXIMATEINTERVAL
<br />onsetto death
<br />> 1 Year
<br />o�reet to death
<br />onsetto death
<br />ZIP CODE
<br />�� 24a. DATE SIGNED (MO., Day, Yr.) 24b. TIIV� OF DEATH
<br />.� �
<br />�� Q� 24c. PRONOUNCED DEAD (A4o., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />g o
<br />8&� 24e. On qre heele o/ eraminaNOn entl/w Imeafipatlon. In my upWon death murted al
<br />e die Hme. tlarte and place and due to the caus�e) s�ed. (Sl9nature and Titte)
<br />r ��
<br />g�
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN � ❑ YES � NO
<br />. W , E�D E����E�� , 1 IST T, N ��H�I
<br />Gene L. Wyse, DO, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br />a. REGISTRAR'S SIGNATURE /�,+._ r �-
<br />L' ltl�rA�L(j � •
<br />�.i.---
<br />HZBaisNO flYE3 I_INO
<br />28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />January 18, 2012
<br />
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