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1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />William Glen Poole
<br />2. SEX'
<br />Male
<br />* 3 u 1:ATE bF . I11EATH(151 16/M)
<br />June 27, 2015 -
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />71
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.) '
<br />September 13, 4943
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />505 -52 -3358
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ❑Inpatient OTHER: El Nursing Home/LTC 0 Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑otller(speoiry)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Wedgewood Care Center
<br />8c. 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 />Grand Island
<br />9d. STREET AND NUMBER
<br />924 West 8th Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />III Yes ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Manied, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) ['wife, give maiden name.
<br />Leona Haussemiann
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Poole Sr
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Christina Sorgenfrei
<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 />Leona Poole
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPO natIon
<br />®B " "" ❑ '
<br />❑Cremation ❑Entombment
<br />0 Removal ❑Otheryspedty)
<br />16a. EMBAL - -S T9,
<br />16b. LICENSE NO.
<br />/2V0
<br />16e. DATE (Mo., Day, Yr.)
<br />June 30, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN - STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. 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 />1a. PART I. Enter the chain of events - diseases, injuries, or complications. that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />,.,/f �-� �,, C l
<br />� v� V v J
<br />1
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting a)p,��A.tR.ita �•� 1e, r 1 �/ ��
<br />In death) T - ' ' ' " _ '
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, If b) �f ' 014 e , i r � / r r f }rt�" t newlefvV 'T7+
<br />any, leading to the cause listed ' �
<br />on line a. DUE TO, I OR AS A CONSEQUENCE OF: onset
<br />onset to death
<br />�.r.-�^.7,�,
<br />( �G
<br />" + -
<br />7 ( (' :4 ,, ` > C ` \ ' / ` " C � ' - q/�'�'
<br />Enter the UNDERLYING CAUSE c) GIE I ( V l 1'1 /
<br />ll
<br />(disease or injury that Initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d) ' 11-
<br />�..�QV�1 M� �} onset ` to death
<br />/�� y ��'� - ��
<br />1 1 ' `° / 1 \i& / l VI l� � C l
<br />- ice , <b- r r r ll 9-1 "
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />i EC '1 T --"VbF � \� - r ierr i 9N-C pNA`O' iZ ` 61t•s'
<br />19. WAS MEDICAL EXAM
<br />. OR CORONER CONTACTED?
<br />❑ YES ill NO
<br />• -
<br />S.-I �--rst
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑Pregnant at time 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 pregnant within the past year
<br />l 21a. MANNER OF DEATH
<br />`Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES N 9rN0
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />K
<br />II LL
<br />E � z
<br />y r O
<br />C 5
<br />23a. DATE OF DEAT (Mo., Day, Yr.)
<br />Z
<br />$ y O
<br />D. z
<br />v W Z O
<br />2 z n
<br />0 I-
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Y)
<br />( �
<br />23c. TIME OF DEATH
<br />4:10 a ,,m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred
<br />at the time, date and place and due to the causes) stated. (Signature and Title)
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to4tTcaus s) state • (Signature and Title)
<br />p ,r � 9 --- " -
<br />25. DID TOBACCO USE CON E TO THE DEATH?
<br />❑ YES E NO ❑ P - ' BABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES .plO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Jana VanWie M.D. 3016 West Faidley Ave., Grand Island, NE 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />d. , , •, ;
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />.I11L 9 2015
<br />a
<br />E
<br />0
<br />0
<br />0
<br />DATE OF ISSUANCE
<br />JUL 14 2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH P1 SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS1 A QfICARTrl¢1tf CK HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY .FQR VTAI RgCORRDS _/ .
<br />S'J•ANL,i=Y -S. COOPER "
<br />ASSIST ISTRA R -°
<br />CiffiAk711 1 ANa
<br />HL/t°T 1N_SERVICES
<br />-
<br />201504940
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />
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