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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE APR 232007 201807461 LINCOLN, NEBRASKA TANLEY S. COOPER ASSISTANT STATE REGISTRAR HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES-FINANCEAND SUP CERTIFICATE OF DEATH 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Everett Charles Wiley 2 SEX Male 5c. UNDER 1 DAY 3. DATE OF DEATH (Mo., Day, Yr.) April 7, 2007 6. DATE OF BIRTH (Mo., Day, Yr.) June 3, 1927 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 5b. UNDER 1 YEAR Grand Island, Nebraska (Yrs.) 79 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506-26-7873 8a. PLACE OF DEATH rVt HOSPITAL: ul Inpatient OTHER: U Nursing Home/LTC ❑ Hospice Facility Bb. FACILITY -NAME (If not institution, give street and number) VA Medical Center U ER/Outpatient U Decedent's Home ❑ co!, U Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 8d. COUNTY OF DEATH Douglas 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1501 North Eddy Street Be. APT. NO 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS W YES U NO 10a. MARITAL STATUS AT TIME OF DEATH hI Married ❑ Never Married U Married, but separated ❑Widowed ❑Divorced ❑Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Betty Lou Schleichardt 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ray M. Wiley 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Nora Belle Brudeen 13. EVER IN U.S. ARMED FORCES? Give dales of service if yes. ((Ye),no, orunk.)O1/31/46-01/26 47 14a. INFORMANT -NAME Betty L. Wiley 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION LXBuriai ❑Donation ❑Cremation UEntombment ❑Removal ❑ Other (Specify) 16a. EMBAL IGNATU 16d. CEMETERY, CREMATO Y RELOCATION Grand Island Cemetery, 16b. LICENSE NO. /L7( CITY/TOWN Grand Island, 16c. DATE (Mo., Day, Yr. ) April 12, 2007 STATE NE 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home 1123 West Second, Grand Island, NE. 17b. Zip Code 68801 0' ., I'� � '� C 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 - _.... ... r• INTERVAL 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: onset to death IMMEDIATE CAUSE (Final (a) Pneumonia weeks disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: I onset to death in death) Sequentially list conditions, it ro) Pneumothorax weeks any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onset to death on linea. Enter the UNDERLYING CAUSE (disease or injury that Initiated (c) Emphysema years the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LASE (d) 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? U ��RR YES til NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant al time of death U Not pregnant, but pregnant within 42 days of death U Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH U Natural ❑ Homicide U Accident Pending Investigation U Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY U Driver/Operator U Passenger ❑Pedestrian ❑Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES l NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? U YES U NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? U YES U NO 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY- STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE To be completed by Attending PHYSICIAN ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) April 7, 2007 24b.TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) April 10,2007 23c.TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 2:50 ,,.m 24d. TIME PRONOUNCED DEAD m 23d. To the best of my knowledge, death occur ed at the time, date and place 24e. On the basis of examination and/or investigation, in my opinion death occurred at and due to the cause(s) stated. (Signature and Title) y the time, date and place and due to the cause(s) stated. (Signature and Title) �� 25.VVDII'D TOBACCO USE CONTRIBUTE TOTHE DEATH? • ,o t YES U NO U PROBABLY U UNKNOWN 26a. HAS ORGAN OR TISSUEDONATIONBEEN CONSIDERED? I 26b. WAS CONSENT GRANTED? U YES Ud NO J Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Harry Lazarte, M.D., VA Medical Center, 4101 Woolworth Ave., Omaha, NE 68105 28a. REGISTRAR'S SIGNATURE 11 IS 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) APR 19 2007