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<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 le
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />8/16/2019
<br />201905684
<br />LINCOLN, NEBRASKA
<br />•
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Dennis V Wells
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 7, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Lexington, Nebraska
<br />(Yrs.)
<br />55
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 16, 1963
<br />7. SOCIAL SECURITY NUMBER
<br />507-98-3092
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />Airport Road And Burwick Road
<br />0 ER/Outpatient ❑ Decedent's Home
<br />0 DOA E Other (Specify)l-Iighway
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)80. COUNTY OF DEATH
<br />Grand Island 68801 I Hall
<br />9a. RESIDENCE -STATE '
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Cairo
<br />9d. STREET AND NUMBER
<br />4775 North 130th Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68824
<br />9g. INSIDE CITY LIMITS
<br />0 YES E NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married El Never Married
<br />0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Kimberly Vavrina
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Jim Wells
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Sue Raetz
<br />13. EVER IN U.S. ARMED. FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Kimberly Wells
<br />14b. RELATIONSHIP TO DECEDENT:.
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />1071
<br />16c. DATE (Mo., Day, Yr.}
<br />August 13, 2019
<br />El Cremation ❑ Entombment
<br />❑,Removal ; ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Hewitt Cemetery Northwest of Lexington Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />ie. 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,
<br />APPROXIMATE INTERVAL
<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) Blunt Force Trauma To Head, Neck And Torso
<br />disease or condition resulting
<br />•n
<br />onset to death
<br />Seconds
<br />death)
<br />DUE TO, OR AS A CONSEQUENCE Or: ' onset to death
<br />Sequentially Hot conditions, if b)
<br />any, leading 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 injury that initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />Pregnant
<br />ElPregnant at time of death
<br />21a. MANNER OF DEATH
<br />0 Natural ❑ Homicide
<br />Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />E Driver/Operator
<br />❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />El YES ® NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Na pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />Suicide 0 Could not be determined
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />August 7, 2019
<br />22b. TIME OF INJURY
<br />Unknown
<br />22c. PLACE OF INJURY -At home,
<br />Highway
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ®NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Deceased s vehicle collided with a downed tree in the roadway, causing the roof of the vehicle to collapse on the
<br />nPrPaSPri
<br />22f. LOCATION
<br />Airport
<br />OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />Road And Burwick Road, Grand Island Nebraska 68801
<br />To be completecby
<br />MEDICAL CERTIF':ER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />To be completed b
<br />CORONER'S PHYSI II.N
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.) 124b. TIME OF DEATH
<br />nUQUSL IL. 2U19 l Unknown23b.
<br />DATE SIGNED (Mo., Day, Yr.)
<br />_____,-�
<br />23c. TIME OF DEATH _
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />August 7, 2019
<br />24d. TIME PRONOUNCED DEAD
<br />03:35 AM
<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 />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 />Thomas J. Helget, Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />El YES E NO El PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Thomas J. Helget, Deputy County Attorney, 231
<br />South Locust Street, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE '7
<br />r
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 14, 2019
<br />
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