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6.) STATE OF NEBRASKA 201901711 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 2 3 2007 LINCOLN, NEBRASKA yyl Gtr", - _ C TANLEY S. COOPER ASSISTANT STATE REGISTRAR HEALTH AND HUMAN SERVICES STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINtoNOEAND SUPP CERTIFICATE OF DEATH U 2 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 HOSPITAL: 1 Inpatient OTHER: ❑ Nursing Home/LTC Li Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOh ❑ Other (Specify) 8b. FACILITY -NAME (If not institution, give street and number) VA Medical Center 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 9e. APT. NO 9f. ZIP CODE 68801 9g., INSIDE CITY LIMITS W YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH YlMarried ❑ Never Married ❑ Married, but separated 0 Widowed ❑ Divorced 0 Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Betty Lou S chle ichard t 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 ((Ye), nn, or unix 01/31/46-01/26/47 15. METHOD OF DISPOSITION f�Burial Li Donation dales of service if yes. 16a. EMBALIGNATU. 14a. INFORMANT -NAME Betty L. Wiley / / 16b. LICENSE NO. /L/(J% 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr. ) April 12, 2007 ❑Cremation ❑Entombment Ll Removal ❑ Other (Specify) t6d. CEMETERY, CREMATO• Y a R OTHER LOCATION CITY / TOWN STATE Grand Island Cemetery, Grand Island, NE 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Slate) Apfel Funeral Home 1123 West1Second, Grand Island, NE. 17b. Zip Code 68801 '$ !�`'S`'�6.._.�.ff df.a.,it.,u�" 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 I respiratory arrest, or ventricular librillalion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I 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) I Sequentially llstconditions, if (b) Pneumothorax weeks any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onset to death on line a. Enter the UNDERLYING CAUSE I (disease or injury that initiated (c) Emphysema ; years the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST (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? ❑ YES q8 NO 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death CINot 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 CI Natural CI Homicide 0 Accident Pending Investigation CI Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY CIDriver/Operator CI Passenger ID Pedestrian CI Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? CI YES p NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ 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? Li YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE To be completed by Attending PHYSICIAN ONLY 23a. DATE OF DEATH (Mo., Day, Yr.)Z April 7, 2007 a Z 4- _ I E„aZ 0 w Z O 2 p p 24a. DATE SIGNED (Mo., Day,Yr.) 24b.TIME OF DEATH m 24c. PRONOUNCED DEAD (Mn., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23b. DATE SIGNED (Mo., Day, Yr.) April 10,2007 23c. TIME OF DEATH 2:50 p,m 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title ) • ' 23d. To the best of my knowledge, death occur ed at the time, date and place and due to the cause(s) statteeddd. (Signature and Title) ♦ 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? A.t YES ❑ NO CI PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? CI YES I7 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 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 2Ba. REGISTRAR'S SIGNATURE *PO! I. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) APR 19 2007