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1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Roger Donald Wilson 2. SEX 4 Male 3. DATE•oF DEATH (91o.,9ay,Yr.) /1 December 14, 2008 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE -Last Birthday (Yrs.) 66 5b. UNDER 1 YEAR 5c. UNDER 1 DAY - 8. DATE OF BIRTH (Mo., Day, Yr.) April 8, 1942 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -50 -1688 8a. PLACE OF DEATH tJOSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedents Home ❑ DOA ❑ other/Speciry) 8b. FACILITY -NAME (If not Institution, give street and number) 835 E. South St. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 835 E. South St. 9e. APT. NO. 91. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® Yea ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Sheila Graves 11. FATHER'S -NAME (First, Middle, Last, Suffix) Joseph Wilson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Irma Prenger 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yea, No, or Link.) N 14a. INFORMANT -NAME Sheila Wilson - 14b. RELATIONSHIP TO DECEDENT Wife 16. METHOD OF DISPOSITION ®Burial Donation ❑ ❑Cremation ❑Entombment ['Removal ❑OtMryBpeciry) 18 E MER.SIt(NAT E l el \ l_.0 c_ 18b. LICENSE NO. ) 9 7 18c. DATE (Mo., Day, Yr.) December 18, 2008 16d. Westlawn CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 16. PART I. Enter the chain of event; - diseases, injuries, or complications- that directly caused the death. DO NOT enter terminal events such as cardiac arrest, t APPROXIMATE INTERVAL respiratory amp, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. - - IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final disease or condition resulting a) in death) senescence as a result of old age unknown DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at 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 21a. MANNER OF DEATH 1 Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ® NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 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 - 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE a 0 rn III a z y v c i u 1+ ~ a 23a. DATE OF DEATH (Mo., Day, Yr.) a 0 z i S O _ Y E H a Z C W Z 2 C C O ~ 0 c 24a. DATE SIGNED (Mo., Day, Yr.) December 31. 2008 24b. TIME OF DEATH 2:28 am 24c. PRONOUNCED DEAD (Mo., Day, Yr.) n „,��, �� 9008 24d. TIME PRONOUNCED DEAD 5r.,1,�,fl a "T 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH m s1LQrgreliMd�a 24e. On t is of examination and/or investigation, in my opinion death occurred to and place and to the cause(.) stated (Signature and Title) Hall Cnunty Attnrnp 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY [ UNKNOWN 28a. HAS ORGAN OR TISSUE DONATION BEEN 0(SIDERED? ❑ YES ® NO 28b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Mark J. Young, Hall County Attorney, 231 S. Locust Street, Grand Island, NE 68801 28a. REGISTRAR'S SIGNATURE i r ,,; 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) JAN 5 2009 P STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTN'AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,,DEP,A(ZTMENT OP HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR gPY PL,,REC,OR[ 5 ., DATE OF ISSUANCE JAN 0 7 2009 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES; CERTIFICATE AF DEATH 201405466 STANLEY S.' COOPER' °; ASSISTANT'STATE REGISTRA bEPAR111ENT OF HEALTH AN HUMAN