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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAR 1 6 2006 LINCOLN, NEBRASKA 201302454 TANLEY S.COOPER ASSISTANT STATE REGISTRAR HEALTH AND HUMAN_SERCES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEANDSUPPORT CERTIFICATE OF DEATH 06 2 :9 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Wesley Steven Sandquist 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) March 10, 2006 ' 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Tilden, Nebraska 5a. AGE -Last Birthday (Yre.) 56 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) January 6, 1950 MOS. DAYS HOURS MINS. 4'c ` 7. SOCIAL SECURITY NUMBER 506 -68 -2084 Ba. PLACE OF DEATH HOSPITAL: ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER /Outpatient XI Decedent's Home ❑ Daa ❑ Other (Specify) Bb. FACILITY -NAME (If not institution, give street and number) Home: 717 East 13th St. " 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska Bb. COUNTY Hall 9c. CITY OR TOWN Grand Island '.. 9d. STREET AND NUMBER 717 East 13th St. 9e. APT. NO 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS Xi YES ❑ NO „'. 10a. MARITAL STATUS AT TIME OF DEATH a Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Melva Umbenhower 11. FATHER'S -NAME (First, Middle, Last, Suffix) Wesley L. Sandquist 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Jeanie James 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, orunk.) No 14a. INFORMANT -NAME Melva Sandquist 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION (tBurial ❑ Donation ❑Cremation ❑Entombment ❑Removal ❑ Other (Specify) 16a. EM M SIGN UR �G 16b. LICENSE NO. /_27 16c. DATE (Mo., Day, Yr. ) March 14, 2006 16d. CEMETERY, CREM 0 Y OR OTHER LOCATION CITY /TOWN STATE Westlawn Memorial Park Cemetery Grand Island, NE a �.'r 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 West Second, Grand Island, NE. 18 PART I. Enter the phain of events - diseases, Injuries, or complications --that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional fines if necessary. I IMMEDIATE CAUSE: ,( 'onset IMMEDIATE CAUSE (Final (a) (....&44-{ a .1 et".-0 Oka ( q- Oa disease 17b. Zip Code 68801 INTERVAL to death l 0 ma_ J - 1 or condition resulting DUE TO, OR ASACONSEOUNCEOF: In death) I onset to death Sequentially list conditions, if (b) COP 0 I any, leading to the cause listed DUE TO, OR ASA CONSEQUENCE OF: on line a. I onset to death Enter the UNDERLYING CAUSE JJ�� (disease or injury that initiated (c) j'1 lc a L. Li Yr the events resulting in death) DUE TO, OR AS .A CONSEQUENCE OF: LAST onset to death - 'N k 4 ! x� + E ,. .,V • atx 4fa k,118. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. ext,N",`. 1 _ ! / '7'D SGT- C.G..�, )09. WAS MEDICAL EXAMINER OR CORONER CONTA TED? ❑ YES 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant al time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year X21a.MANN FDEATH '' atural ❑ Homicide ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21 b. IF TRANSPORTATION INJURY - ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 161c. WAS AN AUTOPSY PERFORMED? / ❑ YES Q.�6 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETECAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY - At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22t. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CRY/TOWN STATE ZIP CODE , v8 z aa y = J 'v f 23a. DATE OF DEATH (Mo., Day, Yr.) 3 - lo -o , z aT c cc d w m i F E� Z 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH m n . d F and .23b. DATE SIGNED (Mo., Day, Yr.) ( y ) `3 /iAA X23c. TIME OF DEATH o� -� 10 m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d TIME PRONOUNCED DEAD m (3d. To the best of my knowledge, death occurred at the.8' - .. ; and place 8 w du the cause(s) stated (Signature / p nl T tl 2 ¢ U YL.I o U S 24e. On the basis of examination and /or investigation, the time, d and place and due to the in my opinion death occurred at cause(s) stated. (Signature and Title ) ‘425. DIDTOBACCO USE CONTRIBUTE DEATH? td'YE3 ❑ NO ❑ PROBABLY ❑ UNKNOWN :a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES i,J.hlt r.. T,4 -" A. ` 4)y 4..4 x26b. WAS CONSENT GRANTED? -{d ot Applicable If 26a Is NO ❑ YES IT N - 0 .-- 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Kenneth L. Vettel M.D. 2116 W. Faidley ve., Grand Island,NE. 68803 28a. REGISTRAR'S SIGNATURE . A. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) MAR 1 5 2006 l STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAR 1 6 2006 LINCOLN, NEBRASKA 201302454 TANLEY S.COOPER ASSISTANT STATE REGISTRAR HEALTH AND HUMAN_SERCES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEANDSUPPORT CERTIFICATE OF DEATH 06 2 :9