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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT;4L RECORDS.
<br />DATE OF ISSUANCE
<br />202201447
<br />5�ANLEY' cdoPER
<br />NOV 1$ 201 B� MAND .
<br />LINCOLN, NEBRASKA HUMAN SERVICESg`;
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES �sffJ Y��
<br />CERTIFICATE OF DEATH O8 4'
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />2. SEX
<br />3. DATE OF DEATH ( - .,Day,Yr.)
<br />Clark Willis Reese
<br />Male
<br />June 22, 2008
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Be. AGE -Last Birthday
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Omaha, Nebraska
<br />57
<br />77T77_=_
<br />November 14, 1950
<br />7. SOCIAL SECURITY NUMBER
<br />Ba PLACE OF DEATH
<br />506-70-8316
<br />Noaw7aL: ® Inpatient OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility
<br />Bb. FACILITY -NAME (If not Institution, give street and number)
<br />❑ ER/Outpatient ❑ Decedent's Homs j
<br />Nebraska Medical Center -University
<br />❑ Doa ❑on,er(apecltyl
<br />8a CITY OR TOWN OF DEATH li clude Zip Code)
<br />TDouglas
<br />ad. COUNTY OF DEATH
<br />W
<br />Omaha 68198
<br />Z
<br />Be. RESIDENCE -STATE
<br />Bb. COUNTY
<br />8e. CITY OR TOWN
<br />Nebraska
<br />Hall
<br />Grand Island
<br />y
<br />8d. STREET AND NUMBER
<br />Be. APT. NO. I
<br />Of. ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />2123 W. Koenig
<br />68803
<br />® Yee ❑ No
<br />10s. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Manied
<br />10b. NAME OF SPOUSE (First, Middle, Lest, Suffix) H wife, give maiden name.
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Karen Ward
<br />E
<br />E
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S•NAME (Fest, Middle, Maiden Surname)
<br />°
<br />t�
<br />Walter Willis Reese
<br />Irma Jahrmarkt
<br />p
<br />m
<br />13. EVER IN U.S. ARMED FORCES? Give dales of service H Yes.
<br />1 14#, INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />12
<br />(Yes, No, or Unk.) NO
<br />reRease
<br />Wife
<br />16. METHOD OF DISPOSITION
<br />16% EMBALMER-WGNATURE
<br />16b. LICENSE NO.
<br />16a DATE (Mm, Day, Yr.)
<br />[]Stinal ❑Donation
<br />Not Embalmed
<br />June 24, 2008
<br />®cmledon ❑Emomtereat
<br />16d.CEMETERY, CREMATORY OR OTHER LOCATION CITYITOWN STATE
<br />❑Removal ❑OlharyapeclW
<br />Autumn Hills Cremation Services Omaha Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />17b. Zip Code
<br />Mid America First Call, Inc., 4425 S. 24th Street, Omaha, Nebraska for
<br />68107
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />68801
<br />CAUSE OF DEATH See instructions and examples);
<br />III.PARTI.Entarthe chan of evenfe • Message, Injuries, or complications. that directly caused the Oath. Do NOT eller terminal events such as c irdlae arrest, I APPROXIMATE INTERVAL � 1
<br />mpiralory arrest or vantreular fibrillation without showing the etiology, DO NOT ABBREVIATE. Eller only one cause on a line. Add additional Imes If necessary, -
<br />1
<br />IMMEDIATE CAUSE: r ansat to death
<br />r
<br />IMMEDIATE CAUSE (Fend ,
<br />Baser condition resulting a) � i t
<br />In ��J�S
<br />In death) �
<br />DUE TO, OR AdA CONSEQUENCE OF: I omet to death
<br />Se"mlally list conditions, M bi r'�+ i
<br />GA i�
<br />any, leading to the cause listed • pelt i
<br />on linea DUE TO, OR AS A CONBEQUENCE OF: l onset to deem
<br />Enter the UNDERLYING causE el A Crum , r►w ►1 e1iO tA
<br />(disease or injury that initiated r
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: , onset to death
<br />LAST
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />W
<br />20. IF FEMALE:
<br />21a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY 21c.
<br />WAS AN AUTOPSY PERFORMED?
<br />U.
<br />❑ Not pregnant within past year
<br />Natural ❑ Homlelde
<br />❑ DrivedOperstor
<br />❑ YES �NO
<br />[]Pregnant at time of death
<br />❑ Accident ❑ Pending Investigation
<br />❑ Passenger
<br />WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />V
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Suicide ❑ Could not be determined
<br />21d.
<br />❑ Pedestrian
<br />.G�
<br />❑ Not pragnank but pregnant 43 days to 1 year before death
<br />❑ Other (Specify)
<br />❑YES KNO
<br />❑Unknown If pregnant within the past year
<br />a
<br />E
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At hone, farm. Street, factory, office building, construction site, eta (Spode)
<br />1
<br />22d. INJURY AT WORK?
<br />1 229. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />22r. LOCATION OF INJURY • STREET i NUMOM APT. NO. CITYITOWN STATE LP CODE
<br />'M
<br />23a. DATE OF DEATH (Mo,, Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />Twu 2,2 200$ g m i
<br />fZ��'
<br />23b. DATE SIGNED 1111c., Day, Yr.) 23c. TIME OF DEATH Q 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />t�INILZ 2� 2008 22.: 0*7m g,a<� m
<br />OI
<br />• 29d. To the bast of my knowledge, death occurred at the time, date and place 24e. On the beats of examination andlor Investigation, in my opinion death occurred
<br />and due to the cause(s) stated. (Siignnaaturee and�nds) g at the time, date and place and due to the cause(@) stated. (Signature and Title)
<br />26. DID TOBACCO USE CONTRBUTE TO THE EATH?
<br />26a. MORGAN OR TISSU DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ PROBABLY UNKNOWN
<br />❑ YES NO
<br />Not Applicable N 26a Is NO []YES ❑NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Dr- Maness-Harrqs MD 42nd street and Emile Street Oma a Ne 68198
<br />P
<br />28a. REGISTRAR'S SIGNATURE nn 28b.
<br />DATE FILED BY REGISTRAR (Md., Day, Yr.)
<br />cX_.JUM4.
<br />2008
<br />
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