|
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />1
<br />re
<br />LL
<br />p
<br />ci
<br />E
<br />O
<br />P
<br />1. DECEDENT'S-NAME (Fist, Middle. . ? Last , MEMO
<br />: CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Abbott, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-50 -9349
<br />9b FACRfTY•NAIIE penal Institution, gb . serest and number)
<br />Saint Francis Medical Center
<br />Be. CITY OR TOWN OF DEATH (Include Zip Cods)
<br />Grand Island 68803
<br />91. RESIDENCE.STATE
<br />Nebraska
<br />94. STREET AND NUMBER
<br />1031 East Phoenix
<br />10.. MARITAL STATUS AT TIME OF DEATH ®Married : ❑ N.wr W
<br />❑ traded, bat separated Widowed ❑ Divorced ❑ U nkne.n
<br />11. PAM ER'B•NAME (First': Middle, test. SOW
<br />Alvin Wrage
<br />13. EVER IN U.S. ARMED FORCES? Gin dates of service It Yee. 141.:INFORMAN•N AME
<br />(Tee, No, orUnk) 8/16/1957- 4/2•/196 Connie Claire
<br />16. METHOD OF DISPOSITION
<br />D err ❑Dosed..
<br />O Cromole. ❑a.o.aen.
<br />❑ Raeow :. .': ❑oaelppNrv)
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (meet, City or Town, Stall)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />11. PART 1. MO., the xyW& agate aa.r...114wlw. psompac41o1y.51.tOmar mewl Owe. DO NOT *Do bOolll.l Irma. arch as cardOe rest, :.
<br />nsptratory a.ar. or ventricular lbI bo..5.. aleaanl.5y. DO NOT ,1I EWATL Enrr Only macaw an a *.. Add asraaW limo 1 anses,y.
<br />IIMEDIATECAU
<br />IMMEDIATE CAUSE (Final
<br />In
<br />disease done) condition resulting <. al tC It
<br />Saquenliely list conditions, I b
<br />aq. lending to. the Cause Noted
<br />on Nno a. ...
<br />Sitar the UNDERLYING CAUSE c)
<br />(asses. or Injury pat Initiated
<br />I1e me tatlMtlrrp In ds5M) . DUE TO, OR AS A CONSEQUENCE OF :
<br />LAST
<br />20. IF FEMALE:
<br />()Not pregnant veldt past year
<br />OPregnrd.10.1. o fdww
<br />prlot pregnarn,:but Pregnant within 42 days of aim,
<br />❑Hot pregnant but pregnant 43 days to 1 year before death
<br />Dunk own program Mein the gait year
<br />22a. DATE OF MJURY
<br />22d. INJURY AT WORK?
<br />ITEM oISO
<br />u J
<br />8 15
<br />DATE OF ISSUANCE
<br />11/28/2012
<br />LINCOLN, NEBRASKA
<br />Wilbur William Wrage
<br />(Mo., Day, Yr.)
<br />OF DEATH (1fo., Day, W.)
<br />2310. DATE
<br />11
<br />ED (
<br />7
<br />TOBACCO: USE CONTRI= E
<br />YES ❑ NO 0 PROBABLY
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />9b. COUNTY
<br />Hall
<br />166 VA , y -SIGNATURE
<br />` ETERY, CREMATORY
<br />Gran • Island City Cemetery
<br />DUE TO, OR AS A CON ENCE OF:
<br />d)
<br />2-
<br />CAUSE OF DEATH (See '? instructions and examples)
<br />S 5
<br />DUE TO, :0- P A CONSEQUENCE OF
<br />2210. Time OF INJURY
<br />m
<br />22.. DESCRIBE HOW INJURY OCCURRED
<br />DEATH?
<br />KNOWN
<br />23c. THE OF DEATH
<br />23d. To thi beet of nb knordedp.,: catoned the lime, data and place
<br />the ousels) ; (' 5 ) sees.
<br />STATE OF NEBRASKA
<br />20130
<br />da. A0E•lant Birthday
<br />ear..►
<br />73
<br />1010. NAME OF SPOUSE
<br />Connie Claire Clay
<br />12. MOTHER'S-NAME (First, MId4N:
<br />Meta Schweiger
<br />21.. MANNER OF DEATH
<br />i t Basal ❑ Homicide Accident ❑Pending Ywspagellon
<br />❑ . Sakide 0 Could not be dsterm red
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT. NO. CITYITOWN
<br />m,
<br />HASOROAN
<br />❑ Yes
<br />5a PLACE OF DEATH
<br />HOSPITAL ® In
<br />EMOtdpatient
<br />CI Don
<br />9o. CITY OR TOWN
<br />Grand Island
<br />Seto
<br />lib. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />941. APT. NO.
<br />2. SEX
<br />Male
<br />4.. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />1 M. COUNTY OF DEATH
<br />Hall
<br />W. ZIP CODE
<br />68801
<br />(First, Mlddl., Last, Suffix) IwIfs, glee msid.a 115515. _
<br />116. LICENSE NO.
<br />CITY/TOWN
<br />Grand Island
<br />19. FART. O. OTHER. SKD9PCANT CONDRKONS- Condflon. anWbe9no to the death but not molting Mier underlying cause given te PART I
<br />2110. IF TRANSPORTATION INJURY
<br />❑ Ddeerlopanmr
<br />❑ P1gag.r
<br />❑ Pedestrian
<br />r S. ❑ Other (SPuile)
<br />22c. PLACE OF INJURY-At homy. fans, street, factory, oNke beading, oaatnwIpn site, Mc. (Specify)
<br />24.. DATE SIGNED (Mo., Day, Yr.)
<br />24.. PRONOUNCED DEAD Ma, Day, Yr.)
<br />TISSUE DONATION BEEN CONSIDERED?
<br />STANLEY S COOPS
<br />ASSISTANTSTATE, % EEISTRAR °
<br />DEPARTMENT OP 1 AND
<br />HUMAN SERVICES'
<br />i R
<br />Maiden Surname)
<br />1
<br />a DATE OF DEATH (MO,Dsy.Yr.)
<br />November 12, 2012
<br />5. DATE OF BIRTH (Mo.,: Day, Yr.)
<br />February 25, 1939
<br />D Nursing Flame/LTC ❑ Hospice Facility
<br />D•cenenrs' Home
<br />❑
<br />Other(Specify)
<br />9g 1945)05 CITY LIMITS
<br />CI Yee. ❑ NO
<br />1410 RELATIONSHIP TO DECEDENT
<br />Spouse
<br />19.. DATE leo., Day, Yr.)
<br />November 16, 2012
<br />STATE
<br />onset to dish
<br />I
<br />, onset to death
<br />Nebraska
<br />to deal)
<br />1 17b. Zlp Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />1 . onset to death
<br />2
<br />19 WAS MEDICAL EXAMINER
<br />OR CORONER :CONTACTED?
<br />•
<br />❑ YES ❑ No
<br />210. WAS AN AUTOPSY PERFORMED?
<br />❑yEg
<br />1,
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />I'
<br />OYES ❑ NO
<br />STATE EP CODE
<br />2410. TIME OF DEATH
<br />24d. TM PRONOUNCED DEAD
<br />I11
<br />24e. On the bowls of exa hudion endior lm.SgMlon, In my opinion death omuned
<br />*the 1101., dab and place and due to the case(.) stated. (SlgnMto a and TIM) >;.
<br />26b WAS CONSENT GRANTED?
<br />Not Applicable if 391940 ❑ YES: 0
<br />27. K ANE, TITLE AND ADORES$ OF CERTIFIER (Type or Print)
<br />Joshua R. Anderson, M.D., 705 Orleans Drive, Grand Island, NE 68803
<br />. REGISTRAR'S SIGNATURE ,[� f Mb. DATE FILED BY REGISTRAR Geo., Day. Yr.)
<br />let (ifts� . NOV 2 6 2012
<br />
|