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Or 0x* M T Ri N = Cn 19 D O p O Male' J1 4. CITY AND STATE OF BIRTH (Hoot in USA.. name country) G D UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Monts. Day. Year/ (Y rsl Sb. o CD m Glade, Kansas _�� rn I co ti 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home 506 -09 -7077 ❑ ER Outpatient ® Residence 8b. FACILITY -Name llf not institution, give street and number/ h-� ❑ DOA ❑ Other(Speaty, r 8d. INSIDE CITY LIMITS W Grand Island Yes ®N1 ❑ M .� D O 9tl. STREET AND NUMBER llncluding Zip Codel rn Nebraska r ; N C N N 11. ANCESTRY le .g Italian. Mexican. German. etc) 12. ❑ MARRIED ® WIDOWED 13 NAME OF SPOUSE III wife . give maiden name) etc .I lSpecdyl White (Speufyl Danish /Irish 7K Mollie Ditter Dec 14a. USUAL OCCUPATION /Give kind of work done during most lab KIND OF BUSINESS INDUSTRY GIl v > O air rn Refrigeration co 16 FATHER - NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME FAugusta William Thomas Wilson M. Gaarde 18 WAS DECEASED EVER IN U.S ARMED FORCES? Iga INFORMANT - NAME (Yes, no, or unk.) I (11 yes, give war and dates of services) No --- - - - - -- LaVonne Moats 191. INFORMANT MAILING ADDRESS. (STREET OR R F D NO CITY OR TOWN. STATE. ZIP) P. 97 Washington, Nebraska 68068 20. ALMER -SIG ATU 8 E WHEN THIS COPY CADS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REEQRb7QAI FILE SMITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC41ftC#ICK WIWCHIS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE -- -= 200102868 A MAR 2 7 2001 ASS /S*AAi STATP0EG/STIgR LINCOLN, NEBRASKA HEALTH AND HUMANSERVICES SYSTEM= STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S1*V10ES- FINWCi Ai SIjFORT VrrAL STATISTICS 0 1 03086 CERTIFICATE OF DEATH - 1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH (Month. Day. Yearl Dale Augustus Wilson Male' March 22, 2001 4. CITY AND STATE OF BIRTH (Hoot in USA.. name country) 5a AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Monts. Day. Year/ (Y rsl Sb. NOS. 1 DAYS 5c. HOURS' MINS Glade, Kansas 94 I January 7, 1907 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home 506 -09 -7077 ❑ ER Outpatient ® Residence 8b. FACILITY -Name llf not institution, give street and number/ 2429 Commerce Ave. ❑ DOA ❑ Other(Speaty, 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yes ®N1 ❑ Hall 9a. RESIDENCE -STATE 9b. COUNTY 9c CI7V. TOWN OR LOCATION 9tl. STREET AND NUMBER llncluding Zip Codel INSIDE CITY LIMITS Nebraska Hall Grand Island 2429 Commerce Ave. 68801 19n Yes ® No ❑ 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY le .g Italian. Mexican. German. etc) 12. ❑ MARRIED ® WIDOWED 13 NAME OF SPOUSE III wife . give maiden name) etc .I lSpecdyl White (Speufyl Danish /Irish NEVER DIVORCED ❑ MARRIED Mollie Ditter Dec 14a. USUAL OCCUPATION /Give kind of work done during most lab KIND OF BUSINESS INDUSTRY 15. EDUCATION (Spi only highest grade completed) Elementary or Secondary (0 -12) College 11 -4 or 5.1 of working tile, even if retired/ Technician Refrigeration 1 Year 16 FATHER - NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME FAugusta William Thomas Wilson M. Gaarde 18 WAS DECEASED EVER IN U.S ARMED FORCES? Iga INFORMANT - NAME (Yes, no, or unk.) I (11 yes, give war and dates of services) No --- - - - - -- LaVonne Moats 191. INFORMANT MAILING ADDRESS. (STREET OR R F D NO CITY OR TOWN. STATE. ZIP) P. 97 Washington, Nebraska 68068 20. ALMER -SIG ATU 8 E 21a METHOD OF DISPOSITION 21b. DATE 21C CEMETERY OR CREMATORY NAME �7 ��. �Bunal Removal Mar. 24 2001 Grand Island City Cemeter 2a FUNER HOME -NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livin ston- Sondermann F.H. ❑Cremation ❑D °natr °° Grand Island Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN STATE. ZIP) 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23. IMMEDIATE CAUSE .'ENTER ONLY ONE CAUSE PER LINE FOR lal. I11. AND (0) 1 I al be ween onset and death ,PART C ^� _j JO IX ( tat xC DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death (b) DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death I Id 1 OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER'( (Ages 10 -54) Yes No (es No Yes No 26a. 261. DATE OF INJURY /MO.. Day. Yr,) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED ❑ Accident ❑ Undetermined M ❑ Swade F] Pending 26e. INJURY AT WORK 26f PLACE OF INJURY - At home, farm. street. factory 269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation ❑❑ Ves No ❑ of builtling, etc. lSpeciy/ 27a. DATE OF DEATH (MO.. Day. Yr) 28a DATE SIGNED (Mo Day. Yr) 28b TIME OF DEATH ZZ •o <w y r � z $ > M 27b. DATE SIGNED /MO. Day. Yr) TIME OF DEATH 28c. PRONOUNCED DEAD (MO. Day. Yr.) 28d. PRONOUNCED DEAD /HOUq g�4- :27c. M M B2 biz the 270 0 the best of my know go'f1 d \eiat�hJo'tc',c{l t/-efl aln.�d�pl�ace anddue if causes) stated. kU �Irt/h1Ce ti 28e. On the basis of examination and or investigation, in my opinion death occurred at the time. dale and Place and due to the causelsl staled. a ° ¢ o ° \e�� \urred /m�e(,tl(ra- /%lo (Si nature and Trilq ► �V V "- - v �-' �Y (Signature and Title ) ► 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES I/ I NO ❑ UNKNOWN �/ ❑ YES NO X ❑ YES 2 NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Print) 'rpm ,08 'G: w; rn o. 211 W. F 4G m EIR 3 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (MO.. Day Yr) MAR 2 6 2001 Lot Eighteen (18) in Block "D ", in Parkview Subdivision, located in the Northeast Quarter (NE 1/4) of Section Twenty Nine (29), and the Northwest Quarter (1/4) (DI