Laserfiche WebLink
9 <br />STATE OF NEBRASKA. DEPARTMENT of HEALTH AND HUMAN SERVICES FINANCE AND <br />SUPP ®L 3 G 3 3 6 <br />CERTIFICATE OF DEATH 311772 <br />VITAL STATISTICS <br />This.1:q.�rtift$s is,b to be a true copy of an <br />Stat, ties,;, oug as Omaha, <br />ung Health Department, aha, <br />a ra e5 seas,.. in'`the rea• to the loft. Reproductions <br />21004 <br />iega co°Dios. 41* <br />Registrars <br />original record on file with Vital <br />Nebraska. Certified copies must have <br />of this green certificate are not <br />1. DECEDENT - NAME FIRST 16100LE LAST <br />. Dennis Dean Wing <br />a. SEX <br />Male <br />a DATE OF DEATH /Moe Oar Yap, <br />January 24, 2004 <br />4. CITY AND STATE OF BIRTH /Knot it USA. nam. ~ay) <br />Si. AGE - Lad Bwrday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />S. DATE OF BIRTH Mtaf& Aar YAW <br />Kearney, Nebraska <br />'Yr' 61 <br />50.m°1: DA's <br />I <br />5a'H01Ns MNS <br />December 21, 1942 <br />7. SOCIAL SECURT V NUMBER <br />505-56-6519 <br />.. <br />ea PLACE OF DEATH <br />H-Ds�l1'AL: [ Ines ant• o <br />0 <br />❑ <br />■ <br />MameHer. <br />Bb. FACILITY • Name Woof mataisbn. ghe SI IWI numbly) <br />Medical <br />Ctr. <br />i <br />ER O7.IMIU. <br />DOA <br />0 <br />Roads. <br />Calm IS ate <br />Univ. of Nebraska <br />Se. CITY. TOWN OR LOCATION OF DEATH <br />• Omaha <br />21. <br />INSIDE <br />Yea <br />CITY LIMITS <br />F3 N. p <br />Be COUNTY CF DEATH <br />Douglas <br />ga RESIDENCE - STATE <br />Nebraska <br />W. COUNTY <br />Hall <br />ga CITY. TOWN OR LOCATION - <br />Grand Island <br />SI STREET AND NUMBER Miuudh,ZP Coati <br />3012 W 16th St.68843 <br />Os. MODE CRY LMMTS <br />YM® Nap <br />10. RACE • aa, While. Black Amman Wan. <br />sW ISoecdyl White <br />11. ANCESTRY lag- Was Msx+un. Os mm MCI <br />(Ss.0.0 American <br />12 a MARRIED p WIDOWED <br />i1 NEVER ❑ DIVORCED. <br />LIMARRIED <br />is NAME OF SPOUSE 0 r*.. gne a a name <br />Carol Joy <br />14a. USUAL OCCUPATION Ow lend ofamA don* ab/Mg mwt <br />119.. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (SP* anly 155055 lade com01/N <br />I <br />al Wedr.g* oven Yr5Y.d) <br />Service Tech <br />Scale Service <br />ENma+w " 10.121 RA* gm <br />� <br />WI8. <br />GC <br />FATHER - NAME FIRST: MIDDLE LAST <br />Ross Wing <br />17. MOTHER FIRST MIOOLE MAIDEN SURNAME <br />Eileen Beck <br />- <br />I8. WAS DECEASED <br />(Yeaeaauirkl <br />EVER IN U.S. ARMED FORCES? <br />aye..givewet.5dYesofser e.6-5-1964/ <br />I Vietnam Era2-2-1970 <br />19a INFORMANT - NAME <br />Carol Wing <br />ye . INFORMANT. SWUNG ADDRESS (STREET OR RAD. NO.. CITY OR TOWN. STATE ESP) <br />3012 West 16th Street Grand Island, Nebraska 68803 <br />20. =- SIGNATU . .: NO. <br />211. IETH000F DISPOSITION <br />Band il <br />Ram <br />21b. DATE <br />01-28-2004 <br />21c CEMETERY OR CREMATORY NAME Co meter1 <br />Grand Island -City <br />22a�rA.A,1� - , <br />Livingston -Sondermann F. H.j <br />❑Canek11 <br />■ <br />Damon <br />a <br />Grand Island, <br />CITY OR TOWN STATE <br />Nebraska <br />229. FUNERAL HOME ADDRESS (STREET OR RFD, NO- CITY OR TOWN. STATE. WI <br />601 North Webb Road Grand Island, Nebraska 68803-4050 <br />23. IMMEDIATE CAUSE - (ENTER ONLY OW CAUSE .PER LINE FOR III. AND(HI <br />Pr C£Ra aat.t.FICtI 14 le M�4�R1�i tn1 ` <br />(a, <br />Plervai batmen <br />21 <br />DUE TO. OR AS A CONSEQUENCE OF- . <br />ibi <br />S' r A n g aA let Iv Trio aDUE <br />Marge baNlaaOrwl erre momMETA <br />TO. CR AS A CONSEQUENCE OF: <br />(C1 <br />karat beaus onset arm magi <br />OTHER SIGNIFICANT CONDITIONS - Canaan contributing b aro death bra not MOM <br />PART <br />a <br />PART al IF FEMALE. WAS THERE A <br />PREGNANCY N THE PAST 3 MONTHS? <br />(Ages 10341 Yes L I No fl <br />24 AUTOPSY <br />Yes ❑ No rola <br />W. WAS CASE DEFERRED TO MEDICAL <br />EXAMBNER Ohl <br />Yes [_ No <br />26a <br />0 ACC/0•111 0 011011181111.11114 <br />2S0. DATE OF INJURY Aft. Day Yr.I <br />2&. HOUR CF INJURY <br />M <br />26t DESCRRE HOW MLJRY OCCURRED <br />❑ Suicide ❑ DeWMMrg <br />• Homicide Investigation <br />We. INJURY AT <br />Yea II <br />WORK <br />No <br />22 E QF BL 1Y %M I . farm sweet Mem <br />alCe buldrr8 <br />28g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />CL <br />I <br />27a DATE OF DEATH (Mo. Oar Yr.).20a. <br />` P2.4414) <br />DATE SIGNED (Mo.. Day. Yr1 <br />286 TIME OF DEATH <br />M <br />S <br />I <br />r <br />27b.Lu DA SIGNED Va. Day. Yr) <br />)tip 1104 <br />270. TIME OF DEATH � �. � <br />11-• M <br />s <br />2Be. PRONOUNCED DEAD /Mb.. Day. Yr.) <br />28d. PRONOUNCED DEAD Moen <br />>� ? <br />270. TotlNbestd my oceurod■Maura plananddnealIS <br />' Caneelal :caseloadf i) <br />(Signature and Tie) le { Y <br />3 a <br />_ <br />28a. On the basisexaminawn <br />y. death marred at <br />dy irees=sofegaton. in <br />010 cad ander <br />r (SgnaM►e and 'MI 10 <br />28. DID TOBACCO USE TO THE DEATH? <br />p YES C M}(z .: .0 UNKNOWN <br />30a HAS ORGAN OR TISSUE DONATION BEEN SIDERED? <br />❑ Yes <br />30b WAS CONSENT GRANTED* ' ''.,�I <br />❑ YES C� 1 "° <br />31. NAME AND ADOSES$'CF « a CORONER'S <br />vik ,�} .. ,: ,Y F� <br />�i <br />PHYSICIAN OR COUNTY ATTORNEY( /Types! Peng <br />i, nip, j7 o3r PleaRAI AA MC9 c(ji CE, chis Q }A, <br />3�:,. REGISTRAq,, ra <br />I <br />v :. _ `. '"'' 1,.,r- <br />320. DATE FILED BY REGISTRAR (Ma Ary: Al 6 r1 'I' <br />FEB _2 2004 <br />This.1:q.�rtift$s is,b to be a true copy of an <br />Stat, ties,;, oug as Omaha, <br />ung Health Department, aha, <br />a ra e5 seas,.. in'`the rea• to the loft. Reproductions <br />21004 <br />iega co°Dios. 41* <br />Registrars <br />original record on file with Vital <br />Nebraska. Certified copies must have <br />of this green certificate are not <br />