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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF�I L``f'H`A�fb`l�IUM�I'V �kVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASlC,4,AE`PAR7IKEN�' OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIa"A4 _R�'C.C1�D� ,.
<br />{ .,�,
<br />DATE OF ISSUANCE �����d���' � : � ` ' °.
<br />S7 S,' LOOP�R i. • , . - ,
<br />11 /14/2011 AS�S�'AN�,�S ,T�1�"E RE����RAR .
<br />DEPAR�M�}1��"�� 1;��41�T� A11/D
<br />LINCOLN, NEBRASKA ; l�#NlP'�AJ11 S�R�!'�CES . �
<br />--_ �� - -_
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVI�ES ^F;' i: �,��•"� - 'q 1 A�7AR
<br />CERTIFICATE OF DEATH ' 4:':�'. �''� � . ^ °` _�- - -. --- --
<br />1. DECEDENTS-NAME (First, Middle, Last, Suffbc) 2t SEX ���:','�+_. ,3,. DAiE OF DFATH (Mo:, Day, Yr.)
<br />Roberta Alene Wells � Female .'' *�.' . Novembe� 4, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY- . 8: DA7E BIRTH (Mo., Day, Yr.) ,
<br />(Y�•1 MOS. DAY9 HOUR3 MINS. � - '
<br />Llttleton, Colorado 75 Februa 20, 1936
<br />7. SOCIAL SECURRY NUMBER Sa. PLACE OF DEATH
<br />508-40-4885 HOSPITAL � InpaUent OTHER ❑ Nmsing Home/LTC � Hoeplce Faclllly
<br />Bb. PACILITY-NAME (If rrot I�tltution, give street ami rwmber) � ERiOutpatle� ❑ DecedeM's Home
<br />�
<br />° Saint Francis Medical Center ❑ ooa ❑ Other(SpecHy)
<br />c�
<br />� 8c. CITY OR TOWN OF DEATH pr�clude Zip Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />�7 8d. STREEf AND NUMBER e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />�, 415 Rosewood Circle 68803 � YES ❑ No
<br />a 10a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Never Marrted 10b. NAME OF SPOUSE (Ftrst, Middle, Last, SufPoc) If wife, give malden name
<br />�
<br />� ❑ nna►►i�, n�n ea��cea ❑ vuiaowea ❑ Divorced ❑ Unknown Bob G Wells
<br />� 11. FATHER'S-NAME (First, Middle, Last, Suftiu) 12. MOTHER'S-NAABE (First, Middle, Malden Surname)
<br />m Clayton Bogue Alda Linke
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates oT servlce H Yes. 14a. WFORMANT-NAME � 14b. RELATIONSHIP TO DECEDENT
<br />� (vee, No, or unk.) No BOb G Wells Husband
<br />,g 1S. METHOD OF DISPOSITION 18a. EMBALMER-SIGNATURE 18b. LICENSH NO. 18c. DATE (Mo., Day, Yr.)
<br />�,° � Burlal ❑ DomaUon
<br />Chris McCoy 1191 November 7, 2011
<br />❑ CremaUon Q Entombment 18d. CEMETERY, CRENWTORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (SpecNy) W��awn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILINO ADDRESS (Street, City or Town, Sfate) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructtons an exam les
<br />1& PART 1. E�rterthe chaln oi eveMS-diaeasea, in)uriea, or compticatlonrtlmt uirectiy causetl Ute ueath. DO N0T emerterminal eva� auch es carulac arrast, ; APPROXIMATE INTERVAL
<br />resplraWry ar�est, or veMricular flbtlllatlon wkhout showi� the etlology. DO NOT ABBREVIATE Fnter only orre cause on a Ilrre. Add adtlttlonal Il�rea If necessary.
<br />IMMEDIATE CAUSE ; o�et to death
<br />mroneowre c,wse �� a) Respiratory Failure. clostridium difftcile Colitls ; Six Dayes
<br />dieea� or eorMNion rewiting
<br />m tleath) DUE TO, OR AS A CONSEQUENCE OF: � onse2{.o death
<br />SequaMlallylistcondidone,lf b)Protracted Illness With Multiple Antibodies � Less �b�n Two Months
<br />anr. ieadme u nre cause umea �
<br />on Ime e. DUE TO, OR AS A CONSEQUENCE OF: � o�et to death
<br />EMe� the UNDEFa.Y1N� CAUSE C �
<br />(disease w InJury tl�at Initiated
<br />��'�" �" d �'� DUE TO, OR AS A CONSEQUENCE OF: � oreet to death
<br />LAST dy ;
<br />78, PART u. OTHER SIGNIFlCANT CONDI770NS�o�ttiitlo� contributl� to the death but rrot resutting in the urMerlyt� cause given In PART I. 79. WAS MIEDICAL EXANONER
<br />Hypertension,hfstory Of Pnaumonla,paroxysmal AMaI Fibrillation,fractured Hip OR CORONER CONTACTED?
<br />� ❑ ves � No
<br />W 0. IF FENWLE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJU 21c. WAS AN AUTOPSY PERFORMED?
<br />LL
<br />� � Na n�e�s Mnu� a �s r � � n� � Ho�wae p o.�e��ro. ��s � No
<br />� � PreB� at dme W death � Acctderrt � Pendi� Investl8atlon ❑ P �� e �
<br />� Noe pregnaM, but pregnantwithln 4z daye of death � Pedestrian 21d. WERE AUTOPSY FlNDINGS AVAILABL
<br />� � SWdde � Could not be determl�l TO COMPLETE CAUSEQ�" DEATH?
<br />� NM PreB�ent. but pregnatrt 43 daye to 1 year before death � Other (sPB���Y)
<br />� � Unlmown B V�e9�ent within Ure paet year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo.. Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY At home, tarm, street, faetory, oftice buAding, wr�struetlon site, ete. (Speeify)
<br />s
<br />.� 22d. INJURY AT WORK? 22e. DESCRBE HOW INJURY OCCURRED
<br />H
<br />❑ YES ❑ NO
<br />92f. LOCATION OF WJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.s November 4, 2011 � � �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ���� Z4c. PRONOUNCED DEAD (Mo., Day, Yr.j 24d. TIME PRONOUNCED DEAD
<br />$ o November 8, 2011 12:14 PM ��
<br />9U. To the best M my knowteGBe. death oceurred at the tlme. 0ate aml place � � 29e. Oa the f�sie ol eraminaUon aMla Im'estiBetlon� In my oPlNOn death occurred at
<br />�� mM due to the cause(s) stated. (Slgnature and Tftle) $ z � the time, date aiM place and due to the causele) efated. (Slpnffiure an0 Title)
<br />~ Jane A. McDonald, MD ~ g s
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 28b. WAS CONSENT ORANTED7
<br />� YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YE9 � NO NotApplicable H28a Is NO ❑ YES ❑ NO
<br />27. E, TITLE AND ADDRESS F ERTIFIER (P SI IAN, YS C 1 TANT, CO N P R U RNEY) (fype or PrIM
<br />Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGIS7RAR'S SIONATURE 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />November 9, 2011
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