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VVr• r 11 ■Vfl • e.- VI •■ moor, • a •
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />William Charles Wetterer Jr
<br />2. SEX a
<br />Male
<br />3t ppte pF y,Yr.)
<br />'sr
<br />P 'June 9,.2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lincoln, Nebraska
<br />6.. AGE -Last Birthday
<br />(Yrs.)
<br />86
<br />6b. UNDER 1 YEAR
<br />50. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 16, 1924
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />507-48 -6793
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient QTHER: ❑ Nursing Home /LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ DecedenVs Home
<br />❑DOA ❑ Otrer(apseity)
<br />Bb. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9d. STREET AND NUMBER
<br />1057 N. Nebraska Hwy 11
<br />9e. APT. NO.
<br />91. ZIP CODE
<br />68883
<br />99. INSIDE CITY LIMITS
<br />❑ Yes © No
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) S wife, give maiden name.
<br />B McCri ht
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Charles Wetterer Sr
<br />12. MOTHER'S•NAME (First, Middle, Maiden Surname)
<br />Jeanette Adams
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Billy Wetterer .
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />18. METHOD OF DISPOSITION
<br />Wand [ionnatlon
<br />❑comadon ❑pntombment
<br />❑Remover ❑omMSP.
<br />Ilia. FJ�AI/A ER ` SIIG , NA 9
<br />l /- /, I � � (
<br />18b. 1JC �°
<br />!I /
<br />16c. DATE (Mo., Day, Yr.)
<br />July 2, 2011
<br />16d. CEMETERY, CRE RY OR OTHER T10N CITY/TOWN STATE
<br />St. Mary's Cemetery Wood River Nebraska
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1e. PART L Enter the chsln orevea - disaeaes, injuries. oreompliweore -Mat directly cawed [ho death. DO NOT eater nodal evens such as cardiac anon. . APPROXIMATE INTERVAL
<br />nspimtory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Eater only one cause en • IM. Add addNIonsl Nos Irnewseery.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting a " 1 :4)e
<br />1 4 ' 1(4-WV"
<br />In death) '
<br />UE OR AS A CONSEQUENCE OF: onset to death
<br />yO
<br />J / , b) y� ( .k.'.) anading to he cause Vinod , t ` °'" "-
<br />lino a.
<br />on lino a. DUE TO, OR AS A CONSEQUENCE OP `J oneat' death
<br />Enter the UNDERLYING CAUSE e)
<br />(disease or Injury that Initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d)
<br />10. PART IL OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />19. WAS MEDICAL. ER
<br />OR CORONER CO CTED?
<br />❑ YES NO
<br />20. IF FEMALE: -
<br />❑Not pregnant within past year
<br />❑ Pregnant al dm. of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />['Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown If pregnantvdthin to past year
<br />21a. MANNER OF DEATH
<br />❑ Natural ❑ Homicide
<br />❑ Accident ❑ Pending InvesUgatbn
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Speclty)
<br />21c. WAS AN AUTOPSY P ORMED?
<br />❑ YES
<br />21d. WERE AUTOPSY FIN 1NGS AVAILABLE
<br />TO COMPLETE E OF DEATH?
<br />❑ YES NO
<br />22a. DATE OF INJURY (Mo., Dry, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY - home, farm, street, factory, office building, constmeton site, eta (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET a NUMBER. APT. NO. CITYrrOWN STATE ZIP CODE
<br />ft
<br />IV
<br />EL 1
<br />3 V
<br />p
<br />~ 9
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 29, 2011
<br />Z
<br />.g• o z
<br />i r O
<br />E rn t
<br />24a. DATE SIGNED (Mo., Day. Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />23 • • SIGNED (Mo., Day, Yr.)
<br />June 0, 2011
<br />23c. TIME OF DEATH
<br />10 :30 a m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />2317o to • t 01 my knowledge, death occurred at to Urn., date and place 3 E
<br />d � - lh ause(s) stated. (Signature end Title) 2 g
<br />~ . Li`o
<br />24e. On the basis of examination andlor Investigation, to my opinion death occurred
<br />at the tine, date and place and due to the cause(s) stated. (Signature and Title)
<br />26 DI OBAC - 0 = E CONTRIBUTE TO THE D ?
<br />YES d r ❑ PROBABLY ❑ MOWN
<br />265. HAS ORGAN OR , ON BEEN CONSIDERED?
<br />❑ YES • .
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable U 211a is NO ❑ YES NO
<br />27. NAME, T1 LE D ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, r SICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />J. n A. Wagoner M.D. °800 N. Alpha Ave., rand Island, NE 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />' I iettitalk A. 6,17*Ri
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUL 5 2011
<br />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 />DATE OF ISSUANCE
<br />MAR 31 2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201502771
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIOE,S•
<br />sreuvLEY ` S. COO
<br />ASSISTANT STATE REGISTRAR
<br />DEPART,MEPLT OF HEALTH ` '(V1>
<br />HUMAN SERVICES . •
<br />
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