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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
<br />DATE OF ISSUANCE
<br />10/0/2019 202001414
<br />LINCOLN, NEBRASKA
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<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Timothy Edison Wetzel
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 2, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-84-7657
<br />a AGE -Last Birthday
<br />(Yrs.)
<br />52
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />402 Said St •
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Cairo 68824
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />402 Said St
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />El DOA
<br />9c. CITY OR TOWN
<br />Cairo
<br />HOURS
<br />MINS.
<br />8. DATE OF BIRTH (Mo: Day,Yr.)
<br />May 29, 1967 r`
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Homs
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68824
<br />0 Hosplce Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ' 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sadie Sue Wetzel
<br />e 11. FATHER'S -NAME (First,
<br />Vernon D Wetzel
<br />m
<br />1
<br />Middle,
<br />List,
<br />Suffix)
<br />.12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Terry M Gravel
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yea, No, or Unk.) NO
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑;Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Sadie Sue Wetzel
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT.
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />October 3, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Crematory
<br />171. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b. zip Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />1S. PART L Enter the chain of events. -diseases, Injuries, or complicadons-that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory avast; or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 5 necessary.
<br />IMMEDIATE CAUSE:
<br />a) Glioblastoma Multiforme
<br />IMMEDIATE CAUSE (Final
<br />disease Or condition resulting
<br />lin death) <..
<br />saquentlally Net ccnditicl d, x ;.
<br />any, leading to the cause listed.;
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />(disease Or tnjurythat Initiated:::
<br />the eosins resulting in death):;
<br />LASTI
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />10 Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chewing Tobacco Use Disorder
<br />onset to death
<br />>10 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />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 />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at dme a death
<br />0 Not ptegnant, but pregnant within 42 days of death
<br />0 Not pregnant, thrt pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />2 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />Ts
<br />22d. INJURY AT WORK?
<br />0 YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION
<br />0 Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Other(Specify)
<br />INJURY
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSYPERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23& DATE OF DEATH (Mo., Day, Yr.)
<br />October 2.„ 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 3, 2019
<br />23e. TIME OF DEATH
<br />07:55 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 TSN)
<br />Kenneth Vette!, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES ❑ NO 0 PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination andlor investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tide)
<br />26a. HAS ORGAN OR TiSSUE DONATION BEEN CONSIDERED?
<br />❑ YES El 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 />Kenneth Vette!, MO, 2116 W Faidley #400, Box 9802, Grand Island, • - ka, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (MO Day, Yr.)
<br />October 4, 2019
<br />
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