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M �. it ,� 6 i k:e aligiaittNN STATE OF NEBRASKA Itz-Zremalh)Xiii;i0 '411:41.1 WHEN THIS .'COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 11/13/2017 LINCOLN, NESRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lloyd Alan Wilsey 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -94 -6218 8b. FACILITY - NAME (If not Institution, give street and number) 1833 Hancock Avenue 0 W 0.' z.. 2 ` 9d. STREET AND NUMBER u_ 1833 Hancock Av.trwe 9a. RESIDENCE - STATE Nebraska . 5a. AGE - Last Birthday (Yrs. ) 55 9b. COUNTY Hall 5b. UNDER 1 YEAR MOS. DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ERtOutpatient ❑ DOA OTHER ❑ Nursing Home /LTC ® Decedent's Horne ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9e. APT. NO. 19f. ZIP CODE J 68803 3. DATE OF DEATH (Mo., Day, Yr.) October 31. 2017 October 31, 1962 6. DATE OF BIRTH (Mo, Day, Yr.) 9g. INSIDE CITY LIMITS n YES ❑ NO >'v 10a. MARITAL STATUS Ar TIME OF DEATH GSl Mar led J Never Mara 3 10c. 1A,,.. OF SP0L = ❑ Married, butseparatetl ❑ Widowed ❑ Divorced ❑ Unknown Jonell Smutny 11. FATHER'S -NAME (First, Middle, Last, Suffix) Leon Orin Wilsey 13. EVER 1N U.S. ARM FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ other (Specify) 17a. FUNERAL HOME N AME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 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, respiratory arrest, of yentrttular 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) Self- inflicted Gunshot Wounds To Head And Chest disease or condition resulting in death) 2 Segirehhally fist tonditlons, If any, teedioq to the Cause listed on line a. Enter the UNDERLYING CAUSE ( lise@ga or miUfTt04t init[pteir. me events resuIinD in death) LAST: 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I 20. IF FEMALE: ❑ Not pregnant' within past year ❑ Pregnant at time of death ❑ ; Not pregnam, out pregnant within 42 days of death ❑ Not pretrnatn, pregnant 43 days to 1 year before death ❑ Unknovnr.:1 pr ndnr wtth .he p.sx yea 22a. DATE OF INJURY (Mo., Day, Yr.) October 31, 2017 22d..INJURY AT WORKV ❑YES Q NO ' 22e. DESCRIBE HOW INJURY OCCURRED Decedent used two handguns to shoot himself, simultaneously, in the center of his chest and right side of his head, lust ahnvP the right par 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 1833 N. Hancock Avenue, Grand Island 23.1. DATE OF i7EATH (Mo., Day, Yr.) . DATE SIGNED (Mo., Day, Yr.) 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause=s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sarah Hinrichs, Hall Deputy County Attorney, 231 S. Locust, P:O. Box 367, Grand Island, Nebraska, 68802 8a. REGtSTRAF S SIG NATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 16a. EMBALMER- SIGNATURE Katie M. Smvdra 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 06:18 AM 2018005 14a. INFORMANT-NAME r, Jonell Wilse CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH ❑ Natural ❑ HOnticide ❑ Accident ❑ Pending Investigation ® Suicide ❑ Could net be determined 23c. TIME OF DEATH 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, atc. (Specify) Basement Of Decedent's Home CITY /TOWN ❑ Pedestrian El Other (Specify) 26a. HAS ORGAN OR TISSUE DONATION BEN CONSIDERED? ❑ YES f NO STANLEY S. ' .OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES t,iiddie, 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Alice Mary Tesmer b. LICENSE NO. 1454 CITY / TOWN Gibbon ❑ YES ® NO 0 Passenger STATE Nebraska 24a. DATE SIGNED (Mo., Day, Yr.) November 1, 2017 24c. PRONOUNCED DEAD (Mo., Day, Yr.) October 31, 2017 06:38 AM onset to:, i5e 14b. RELATIONSHIP; TO DECED.ENT;: Wife 16c. DATE (Mo., Day, Yr.) November 3, 2017 STATE Nebraska 1713. +Zip Code 68801 APPROXIMATE INTERVAI„ Immediate onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? YES ❑ NO 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED ? ;r ❑ Driver /Operator 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO ZIP CODE 68803 24b. TIME OF DEATH Approx. 06:18 AM 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination andfor Investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Sarah Hinrichs, Hall Deputy County Attorney 26b. WAS CONSENT GRANTED Not Applicable If 26a is NO ❑ ' ES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo.,. Ow, Yr.) November 2, 2017