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To be completed /verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) f Wesley Junior Cornelius 2. SEX c w " Male "' . "'= F1SL'ATH (Mo., Day, Yr.) � •er31, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Blue Hill, Nebraska 5a. AGE - Last Birthday (Yrs.) 82 5b. UNDER 1 YEAR 5c. UNDER 1 4 g6.'DATE OF BIRTH (Mo., Day, Yr.) October 25, 1933 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -46 -5813 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Wood River 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Adams 9c. CITY OR TOWN Kenesaw 9d. STREET AND NUMBER 2377 42nd Road 9e. APT. NO. 9f. ZIP CODE 68956 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Diane UhriCh 11. FATHER'S -NAME (First, Middle, Last, Suffix) Clarence Cornelius 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Helen Stupenhorst 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 05/16/1956 - 02/19/1958 14a. INFORMANT -NAME Diane Cornelius 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Derek Apfel 16b. LICENSE NO. 1240 16c. DATE (Mo., Day, Yr.) January 6, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE St. Paul's Lutheran Cemetery Lowell Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be co mpl ete d by : CE 18. 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, APPROXIMATE INTERVAL onset to death Years respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Parkinsons Disease disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, it b) I any, leading to the cause listed i I on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) I r 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Dementia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El 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 ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES DD 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 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE I23a. DATE OF DEATH (Mo., Day, Yr.) j; 5 December31, 2015 To be completed by COROYER'S PHYSICIAN or COUNTY ATTORIJEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH r 23b. DATE SIGNED (Mo., Day, Yr.) CI. LIJ z January 7, 2016 23c. TIME OF DEATH 04:29 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD Q 3 To the best of my knowledge, death occurred at the time, date and place _. end due to the cause(a; stated. (Signature and Title) Travis S. Hageman, MD 24e. On the basis of examination and/or Investigation, in my opinion death occurred at the time, date and place and due to t'+e cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Prin Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 • 28a. REGISTRAR'S SIGNATURE � 1 f v V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I January 7, 2016 DATE OF ISSUANCE 01/11/2016 STATE OF NEBRASKA 201800463 (�Kab�g�p X03 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECbRD ON FILE WITH THE NEBRASKA D r 1A1 NT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR . V,sltC li • ST�1 NLEY S'- G PER �` • �E ?I?{ E r tALnI; LINCOLN, NEBRASKAIUMAN SERVICES 1' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH