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<br />STATE OF NEBRASKA � ��.�,� � 5 � 8
<br />WHEN'THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE,4LTH �INp HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE W1TH THE.NEBIL4SKA DEPA�,T,(NENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL R�E2)RDS �"+ ��
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<br />DATE OF ISSUANCE -� ��- "�y s - - " .�
<br />'�/;� ' T''+ �. ,� - �
<br />03/01/2012 , STA,NL�r� -�'� �. �,
<br />'� ASSIS�"A1�7" STAT�•R�€GISTRAI2, , �;'
<br />DEf?AR�'MEN ♦UF-kIE�LT�AND a'" �',,
<br />LTNCOLN, NEBRASKA lillMlb�l �C�k�i�� �' f `�� f r
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND SERVIC�S .: ;, ��'�-�/ OOSG4
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<br />�.�rc � �ri�.Hi � �r vr�� n ;,o: -,> •. �, -
<br />1. pECEDENT!3-NAME (First, Mfddle, Last, Suftbc) 2. SDC �.' �� �' • 31DAtE OF DEATH,( o„ Day, Yr.)
<br />Alvin Lee Wagner Male ;„' �,�,�' bruary 22, 2012
<br />4. ITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last BlRhday b. UNDER 1 YEAR 5c. UNDER 7 D Y; 8: DATE OF'qIRTH (Mo„ Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS ANNS. ��
<br />Lincoln, Nebraska 78 April 8,�1933
<br />7. $OCIAL SECURITY NUMBER Ba. PLACE OF DEATH "
<br />50&26 �� InpaUent THE � Nuraing HomeILTC ❑ Hospice Facllityr
<br />8b� FACILITY•NAME (Ii rrot Institutlon, give street arM number) ❑ ER/OutpaUerrt ❑ DecedeM's Home
<br />�
<br />� �akeview-A Golden Living Center ❑ DOA ❑ otner (speciry>
<br />� 8c„CITY OR TOWN OF DEATH pnctude Zip Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68801 Hall
<br />� 9a� RESIDENCESTATE 9b. COUNTY 8c, CITY OR TOWN
<br />Z Nebrask� Hall Grand Island
<br />LL 8d� STREET AND NUMBER 9e. APT. N0. 9L ZIP CODE 9g. INSIDE CITY LIMITS
<br />a 103 St.,Paul Road 68801 � vES ❑ No
<br />� 10a. MARITAI,. STATUS AT TIME OF DEATH � Marrted � Never Marrled 70b. NAAAE OF SPOUSE (Flrst, Mlddle, Last, Suffhc) It wNe, glve malden reme
<br />_ ❑ nnaMed, bu� separacea ❑ vndowea ❑ on�o.ced ❑ unicnown q�ene K Mlckelsen
<br />d
<br />11. FATHER'S-NAME (Firat, Middle, Laet, Suffi�c) 12. MOTHER'S•NAME (Firet, Middte, Maiden Sumame)
<br />m Henry Wagner Henrietta Roth
<br />°' 13, EVER IN U.S. ARMED FORCES? �Ive datea of aervice H Yes. 14a. INFORMANT�NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />Q jves, No, or un�c.) Yes 04/20/1953-07/17/1955 Arlene K Wagner Wife
<br />� 15. METHOD pF DISPOSRION 18a. EMBALMERSI�NATURE 16b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burlal ❑ Donadon
<br />Chris McCoy 1191 February 27, 2012
<br />❑ CremaUon ❑ E�rtombme�rt 78d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />�] Removal ❑ Other (Specify)
<br />Oak Ridge Cemetery Dannebrog Nebraska
<br />17d. FUNERAL HOME PIAME AND MAIUNG ADDRESS (SVeet, CHy or Town, State) 17b. Zip Code
<br />bpfel Funeral Home, 11�3 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See nstructlons and exam les
<br />1& PART I. F�rte� the ehaM oi eveMe-dlsaases, InJuriea, or compiimdone�fhat Alredly caused tlre death. DO NOT e�rter terminal everrte sueh as cardlae erteat, ; ApPROXIMATE INTERVAL
<br />',,';, resplratory� artest or ve�rtriwlaz fIbHllaUon without ehoxring Gre edology. DO NOT ABBREVIATE Errtar only o�re cause on a Ii��re. Adtl edtlRlonai p�rea Ii neceseary.
<br />IMMEDIATE CAUSE: ; onset to death '
<br />�maneoa�cause�nai a)RespfratoryArr�st ; Immediate
<br />ai9ease or conEWon resulting
<br />�° ��� DU� TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />uentially 118t candklons, It b) Chronic Obstructive Pulmonary Disease � Chronic
<br />an . Ieading tq the cause Ilated
<br />on, nrre a. DUE TO, OR AS A CONSEQUENCE OF: ; orreet to death
<br />E�rter the UNDERLYINO CAUSE �)
<br />(disease or InJury that Initlffied
<br />ure B"8"m reaWU"e �" ae�� DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />�ASr d)
<br />�
<br />18:'PART II. qTHER SIGNIFlCANT CONDITIONS-Comlitlo� contributing to the death but nat resulUng In the underiytng eause glvan in PART 1. 19. WAS MEDICAL EXAMINER
<br />R�9ht Heart Failure OR CORONER CONTACTED?
<br />� ❑ ves p No
<br />� 0.';IF FEMAL�: 21a. NUWNER OF DEATH 21b. IF TRANSPORTATION INJU 21c. WAS AN AUTOPSY PERFORMED?
<br />� � NotpregnaMwithin pastyear � Naturat � HoMcide � DrivedOperator
<br />� Q PreB�tattlme otdeatfi � awaeM � PenAIn9lmeetl8�on ���ee� O ves � No
<br />Not pregqant, but prepnant wlthln 42 days o1 death � pedestrlan 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� � � Suldde � cowa nn oe aemrmi�rea TO COMPLE7E CAUSE OF DEATH?
<br />� Not pregnant, but pregnaM 43 daye W 1 year bafore death � Wimr (Specify)
<br />d
<br />p Unknawm�B pregna�rt within the past year ❑ YES ❑ NO
<br />°' 22a. DATE O INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY-At home, fartn, etreeR faetory, otflce bulidt�, co�tructlon ske, atc. (SpecHy)
<br />E
<br />�
<br />.� 22d. INJURY AT WORK? 22e. DESCWBE HOW INJURY OCCURRED
<br />F� ,
<br />' ❑ ves ❑ tvo
<br />?ZfF LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />° 23ar DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. 71M8 OF DEATH
<br />� ebruary 22. 2012 s � �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k y 24c. PRONOUNCED DEAD (Mo, Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E Z �ebrua 23, 2012 12:20 AM g
<br />$� 0 . o Ne Eeat oi my Imowledge. death occurretl at Ure Ume. date antl ptace $ R�� 24e. On the basle Me:eMnation antl/or Imestl9�on. ln my aPlNOn death otturted et
<br />� aea aue m ure cau�ca) sptea. (s�9�arure ana r�ne) 8 z ��, ��d plaae end due to tite cause(e) etated. (Signature and Tlfle)
<br />~ Ryan D. Crouch, DO ~� 6
<br />2$,, DID TOBqCCO USE CONTWBUTe TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />� YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appllcable H 28a la NO ❑ YES ❑ NO
<br />2. E, T D DRE O ER ( HY C , 3 STANT, CORON 9 P SICIAN R U (Typa or Print)
<br />Ryan D: Crouch, DO, 800 N Alpha Streat, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIONATURE � 28b. DATE FlLED BY REGISTRAR (Mo, Day, Yr.�
<br />_.
<br />February 28, 2012
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