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STATE OF NEBRASKA
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
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<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />7. SOCIAL SECURITY NUMBER
<br />505 -72- 4552
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Cairo 68824.
<br />t . RESIDENCE -STATE
<br />9d. STREET AND NUMBER
<br />8020 North Equus Lane
<br />lOa MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown
<br />WHEN THIS < "COPY CARRIES THE RAISED SEAL !OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />4/25/2017
<br />LINCOLN, NEBRASKA
<br />Donald Joseph Wetterer
<br />Grand Island, Nebraska
<br />8020 North EquuS Lane
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Wetterer
<br />13 EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(YesNo,or 11/29/1974- 11/28/1977 Molly Stewart
<br />15. METHOD OF DISPOSITION 16a. EMBALMER- SIGNATURE
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal 0 Other (Specify)
<br />Chris McCoy
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cameron Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />CAUSE OF DEATH See instructions and exam.les
<br />a PART!. Enter the .Chain of events -- diseases, injuries, or complications-that directly caused the death. DO NOT entertenriinal events such as cardiac arrest,
<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 a) Metastatic Cancer Tonsil
<br />disease or condition resulting
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially net cond tionc, if ': i'
<br />any, reading to the Cause listed
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c )
<br />( disease or inyury that initiated
<br />he events resvhingin eeath) nuc rn no AS A Cr1NSF01IFNCF OF'
<br />tAsT d)
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Nbt Pregnant, IRA pregnant within 42 days of death
<br />Not pregnant, but pregnant' 43 days to 1 year before death
<br />❑ viknown if pregnant eft* the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />224. INJURY AT woRK7
<br />❑Y> s C�NC7
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN
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<br />DATE OF DEATH (Mo., Day, Yr.)
<br />April 14, 20'17
<br />23b. DATE SIGNED (Mo., Day, Yr,)
<br />April 17, 2017 09:09 PM
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />23c. TIME OF DEATH
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />ohnA. Wagoner, MD
<br />28a. REGISTRAR'S SIGNATURE
<br />201702792
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />62
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />10b. NAME OF SPOUSE (First, Middle,
<br />Christianna Surprenant
<br />1 12. MOTHER'S -NAME (First,
<br />Billy MCCright
<br />14a. INFORMANT -NAME
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />Sb. UNDER 1 YEAR
<br />MOS.
<br />9c. CITY OR TOWN
<br />Cairo
<br />Pedestrian
<br />OtheT (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />25. Dip TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN DYES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />John A. Wagoner, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />DAYS
<br />9e. APT. NO.
<br />STANLEY S. 'COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />OTHER ❑ Nursing Home /LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />16b. LICENSE NO.
<br />1191
<br />9f. ZIP CODE
<br />68824
<br />Last, Suffix) If wife, give maiden name
<br />CITY I TOWN
<br />Wood River
<br />July 1, 1954
<br />Middle, Maiden Surname)
<br />STATE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />6. DATE OF BIRTH (Mo., Day
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INT
<br />onset to death
<br />2 Years
<br />onset to death
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />24e. On the basis of examination and /or investigation, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 14, 2017
<br />[I Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />❑ YES IJ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)'
<br />April 19, 2017
<br />;VAL
<br />9. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES N0
<br />21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOF'SYPERFORMED?
<br />Driver /Operator ❑YES ® NO
<br />❑ Passenger
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD ::..
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day Yr.)
<br />April 20, 2017
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