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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL pF THE NEBRASKA DEPARTMENT OF HEALTtiiire,MAAWil
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA $10tilltri4thlyf
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO 127170 R S... /7
<br />DATE OF ISSUANCE
<br />'JUL
<br />08 2011
<br />LINCOLN, NEBRASKA
<br />20.20026 20
<br />ItvL Y; �
<br />ApS(STANS
<br />DEIRWMENT OF HE ' 4N
<br />H%M f-5 V1cE5' �j� ^yr '✓
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES,
<br />as IT CERTIFIES
<br />ALrH AND
<br />11'25551
<br />To Be CompletedNerified by: FUN
<br />1. DECEDENTS -NAME (First, Middle, Last, SuNix)
<br />William Charles Wetterer Jr
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Me.,Day,Yr.)
<br />June 29, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />6a. AGE -Last Birthday
<br />6b. UNDER 1 YEAR
<br />Se. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Lincoln, Nebraska
<br />(Yrs.)
<br />86
<br />MOS.
<br />-
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 16, 1924
<br />7. SOCIAL SECURITY NUMBER -.
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ® inpatient QIHEB; ❑ Nursing Homo/LTC 0 Hcaplet, Facility
<br />507-48-6793
<br />Bb. FACILITY -NAME (If not trisection, give street and number)
<br />0 ER/Outpatient 0 Decedent's Hone ..
<br />❑ bOA ❑Olh.rtsp.eny)
<br />Saint Francis Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Ed. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9d. STREET AND NUMBER
<br />1057 N. Nebraska Hwy 11 .
<br />9e. APT. NO.
<br />W. ZIP CODE
<br />68883
<br />9g. INSIDE CITY LIMITS
<br />❑ Yes ® No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Mewled, but separated ❑ Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name.
<br />Billy MCCright
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Charles Wetterer Sr
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Jeanette Adams
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Billy Wetterer
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16. METHOD OF DISPOSITION
<br />Macre ['Donatione\.j
<br />16a. ER-SIGNA E�%�
<br />�/ /Irl '•
<br />lob. UCEN 110.
<br />`/ /
<br />16c. DATE (Mo., Day, Yr.)
<br />July 2, 2011
<br />Enece 't
<br />❑cnmrlon ❑ m
<br />Dens ' ❑othalapeeiryl
<br />lEd. CEMETERY, CRE ORY OR OTHER TION CITY/TOWN STATE
<br />St. Mary's Cemetery Wood River Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b• Zip Code
<br />88801
<br />Toes Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />ta. PART I. Enter the ,eta. - amens, In)urM., or complications- that directly aimed the death. DO NOT quer temdna eosins such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />mpiratery armt. or raceme abdeatlon without showing the etiology. DO NOT ABBREVIATL Enter only one cause ons One. Add additional ane if mammy.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final ' e .
<br />disease or condition resulting a) (A. f {' WM',ryt' (,4
<br />In death)
<br />onset to death
<br />A,✓ e . -
<br />UE 0, OR AS A CONSEQUENCE OF: 1
<br />Sequentially Iles conditions, 9 t d -t -, t�-L'' -
<br />any, leading to the cause listed b:1��,i1Jr 'C, t�'t/L,l%L 2.. , ....
<br />onset to death
<br />l/ 71.9 0' ;-
<br />/
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF:
<br />���.....////
<br />Enter the UNDERLYING CAUSE C)
<br />`L
<br />oneet'to death
<br />(disease or injury that initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<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 L
<br />19. WAS MEDICAL EX INER
<br />OR CORONER TED?
<br />❑ YES NO
<br />20. IF FEMALE:
<br />❑Not pregnant within past year
<br />21a. MANNER OF DEATH
<br />0 Natural ❑ Homicide
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />21c. WAS AN AUTOPSY P FORMED?
<br />❑ YES 0
<br />❑Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />['Unknown If pregnant within the past year
<br />0 Accident 0 Pending investigation
<br />0 Suicide 0 Could not be determined
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE.NUTOPSY FIN NOS AVAILABLE
<br />TO COMPLETE E OF DEATH?
<br />❑ YES NO
<br />22.. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES 0 NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET S NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />�'W
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 29, 2011
<br />Z
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />I2
<br />YE i
<br />SIGNED (Mo., Day, Yr.)
<br />June 0r 2011
<br />23e. TIME OF DEATH
<br />10:30 a m
<br />.b'vZ
<br />s ( O }
<br />3E'a)a z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />8`Oo�
<br />V
<br />8 w
<br />the
<br />o
<br />~2
<br />23� To the beat
<br />`isle due
<br />/
<br />of my knowledge, death occurred
<br />to pause(s) ted. (Signature
<br />tilt,../-
<br />at the time, date and place
<br />and Title)
<br />0
<br />LI Wk
<br />. C O
<br />~ V `O
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />2 DI C{C-O' E CONTRIBUTE TO THE D
<br />YES L.1 0 PROBABLY 0
<br />H?
<br />NOWN
<br />26a. HAS ORGAN OR TISSUE DO TION BEEN CONSIDERED?
<br />0 YES O
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26s is NO 0 YES V
<br />27. NAME, TI LE 0 ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />n A. Wagoner M.D. 800 N. Alpha Ave., Grand Island, NE 68803
<br />\!
<br />28a. REGISTRAR'S SIGNATURE
<br />/r
<br />4'. L
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUL 6 2011
<br />
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