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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL1H AMOMMINAPI.
<br />SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE OR
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL- STAT
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />MAY 16 2008
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMA
<br />To Be CompfetedNeritied by: FuRERAt11REC OR 1
<br />Vcr\r rir nomI c *or VGA• a7
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Charles Lynn Wilson
<br />-�-
<br />2. NBC'
<br />Male
<br />:II t m r " 111.' "
<br />4 - . �v4 • f
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Se. AGE -Las Birthday
<br />61a UNDER 1 YEAR
<br />8c. UNDER '1 DAY,`"
<br />IL bATE • BIR'flW(MP., Day. Yr./
<br />Bradshaw, Nebraska
<br />(Yrs.)
<br />74
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />.
<br />January 2, 1934
<br />7. SOCIAL SECURITY NUMBER
<br />505-36-8600
<br />8a. PLACE OF DEATH
<br />HOSPITAL•QInpatient MEM 0 Nursing Home/LTC 0Hospice Fadlllty
<br />8b. FACILITY -NAME (If not InstituSon, give street and number)
<br />343 Hall St. •
<br />0 ER/Outpatlent ® Decedent's Home
<br />0 DOA OD�asvagr)
<br />80. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />ea. RESIDENCE STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />343 Hall St
<br />9e. APT. NO.
<br />91. LP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />H Yes Q No
<br />108. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Marled
<br />❑ Marled, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name.
<br />Doris Larson
<br />11. FATHER'S -NAME (Firs, Middle, Last, Suffix)
<br />Clifford Wilson
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Myrtle Misner
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service HYes.
<br />(Yea, No, or Unt.) No
<br />14a. INFORMANT -NAME
<br />Doris Wils n
<br />14b. RELATIONSHIRTO DECEDENT
<br />Wife
<br />18. METHOD OF DISPOSITION
<br />Qeunat QOoneaon
<br />18e. r�,�p�\e•�-MER-SI
<br />t \ I�q���o�y� j \ i4�','/
<br />J '✓
<br />18b. LICENSE NO.DATE
<br />6 V / /
<br />(Na, Day, Yr.)
<br />April 30, 2008
<br />IA Cremation °Entombment
<br />QRemovel QOuderySpeciry)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATI CITY/TOWN STATE
<br />Central Nebraska Cremation Service Gibbon Nebraska _
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stab)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. EN Code
<br />68801
<br />�%�'� To Be Completed by; CERTIFIER
<br />CAUSE OF DEATH (See Instructions and examples)
<br />15. PART L Entente EIRE Nevmda -diseases. Injuries, or complications -Mat directly caused the duds DO NOT enter terminal events such as cardiac amu, 1 APPROXIMATE INTERVAL
<br />tospimtory mast, or vaeelatbrnbrillation without showing to etiology. DO NOT ABBREVIATE. Eider only one cause on a Ian. AddadWeaat Enos H nawsutr.
<br />IMMEDIATE CAUSE: ' onset to death
<br />IMMEDIATE CAUSE (Final
<br />disease Orcondition resu'ting a) cardiac arrest.., 145 minutes
<br />M death)
<br />I
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to dealt
<br />eny �. d�ngt thst e cause b) atrial fibrillation 1 unknown
<br />on Una a. DUE TO, OR AS A CONSEQUENCE OF: - i onset to death
<br />Enter the UNDERLYING CAUSE c) 1
<br />(disease or *Bu f that(delated 1I
<br />thee events re
<br />vents sddtlng in death) DUE TO, OR AS A CONSEQUENCE OF: onset to deathLAST
<br />1
<br />d) t
<br />18. PART II. OTHER SIGNIFICANT CONDmONS-Conditions contributing to the death but not resulting In the underlying cause given In PART L
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES Q NO
<br />20.1F FEMALE:
<br />❑ Not pregnant within past year
<br />21a. MANNER OF DEATH
<br />in Natural 0 Homicide
<br />31b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />❑Pregnant at gee of death
<br />ONot pregnant, but pregnant within 42 days of death
<br />ONot pregnent, but pregnant 43 rays to 1 year before death
<br />QUnknown H pregnant within the past year
<br />0 Accident Q Pending Investigation ,
<br />0 Suicide 0 Could not be determine
<br />Q Passenger
<br />0 Pedestrian
<br />0 Other (SpeaHy)
<br />21d. WERE AUTOPSY FINDINGS -AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />Q YES ®NO
<br />22e. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At tome, farm, street, factory, owe building, eonsbucdon ala, etc. (Spsegy)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE YIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />May 7, 2008
<br />246. TIME OF DEATH
<br />6:00 am
<br />II
<br />cg
<br />236. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />m
<br />�kf
<br />1 F
<br />twl<- g
<br />240.RO
<br />PRONOUNCED DEAD (Mo., Day, Yr.)
<br />April 28, 2008
<br />24d. TIME PRONOUNCED DEAD
<br />6:53 a m
<br />c
<br />!D- i
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />81
<br />, _
<br />F
<br />S
<br />24e. On the bests of examaadon and/or Invesdgation, ht my opinion death occurred
<br />at the time, date and pace and due to the cause(s) stated. (Signature end TRU.)
<br />,,-' Hall County Attor
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY $a UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED
<br />0 YES )0 NO
<br />213b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO 0 YES ®NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Mark J. Young, Hall County Attorney, 231 S. Locust Street, Grand Island, NE 68801
<br />P
<br />28a. REGISTRAR'S SIGNATURE
<br />,(�.
<br />2a. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAY 14 2008
<br />
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