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° �-� ��3sss S�TH/S COPY GUtIt�S THE RAISED SEAL OF THE NEBRASKq HEALTH - S C�� JI�IT CERTAFlES TME BELOW TO BE A TRUE COPY OF THE ORIGI ��+ THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEII�VITAL STA � TME LEOAL DEPOSITORYFOR VITAL RECORD� =-��,_ ; ^:.�=_- f y � Ya� �� DATE OF ISSUANCE _ �R 41999 _ .� .,� � - _= ��'� : �- uivcouw n�eRasKa Hea�rH ai�!�. 'T�� ' � STATE OF NEBRASKA-DEPARI'MENf OF E�ALTH AND HUMAN SER SI�RT VITAL STATlSTICS --'=� '*r�: CERTIFICATE OF DEATH �`�r�;; 1.DEGEDENT-NAME FIRST MIDDLE ' UST . 2.SEX °;��3.'DATQ bP pEATM /MOrrM.Day.Year1 Arcle LeRo Willis Male:,i Feb �� 8 1999 4.CITY AND STATE OF BIRTH lMnd h 1LSA.neny eqMr6yJ Sa.AGE-Lal1 BirUqay UNDER 1 YEAR UNDER 1 DAY �6.DATE OF&RTH /AbnM.Dey.Year/ (Vrs.l Sb.MOS. I OAYS Sc.HOURS' MINS. Inde ndence Missouri 72 Feb 14 1926 7.SOCIAL SECURTIV NUMBER Ba.PUCE OF DEATH 514-20-7653 H0SP1TAL � I�� OTHER: � Nuroing Home 8b.FACILITY•Name /l/nd insbh�0vn.8^e sbeM and mxnbsr/ -- � ER Ou��tiern � RssMence $t FY' riC�S ❑ °OA ❑ ome��sox�y� Bc.CITV.TOWN OR IOCATIpN OF DEATH . . !C.INSIDE CITY LMNTS . 89.COUNTY OF DEATH Granc] I^s - - . ., v� [� No ❑ 9a.RESIDENCE-STATE 9C.COUNTY�� 9c.CIiV.T6WN Op LOCATION Btl.STREET AND NUM6ER pncNdiqlp Cotls� ge.INSIDE CITV UMITS Nebraska Hall Gracld Island � 2103 Grand Island8Ave �M� No❑ 1Q RACE-(s.g..Wlvie.8lack.American kMian. 11.ANCESTRV Ie.g..Italian.Mexican.Gerrtyn elcl 12.n MqqRIED ❑NrIDpWED 13.NAME OF SPOUSE /0 wile.givs rryiden ngme/ «c.IlSpec�yl �i� fSpeeMl �tJ �Y•lCan NEVER pIVORCED �n� VQO�,�S 14a USUAL OCCUPATION /Give kiipd rwk abne oYri�g npsf O tOD.KIND OF BUSINESS INW STRY �O� 15.E WCATION �Spocily qNy Mgh�s1 gra0e cpnpl9Md� d��.��1 - EMmemaryaSecon0ary10-t2) �' Cdlegelt-aw5�� Su in n i 16.FATHEF-NAME FIRST MIODLE UST 17.MOTHER FIRST MIDDLE MAIDEN SURNAME t8.WAS DECEASED EVER IN U.S.ARMED FORCES? t9a.�NFpRMANT-NAME (Vef.no.ar unk.) IN yes.grve war ertl dales d servbesl . . 19b.INFOqMANT MAlLM1G ADDRESS (STHEET OR H.F.D.NO.,CITY OR TOWN.STATE.ZIP) . - ZO.EM LMER-SIGNATURE d LICENSE N0. 2ta.METHOD OF q SITION 21b.DATE 21c.CEMETERY OR CREMA70RV�NAME /D �]�� ❑�� Feb. 11 1999 Richland Cemet a.FUNERAL HOME- AME 21d.CEMETEHV OR CREMATORY LOCATIOtJ CITY OR TOWN STATE Kleine Funeral Hom�e ��'°�'�^ �°°^��°^ ette Nebr ka 22b.FUNERAL HOME ADDRESS �STREET OR R.F.D.NO..pTV OR TOWN,STATE.ZIP� 3213 W. North Front St Grand Island Nebraska 68803 IMMEDIATE CAUSE /^� \ �ENTER LV ONE CA PER U FOF 1a41b�,AND�c�) i intervai between onset and aeam � P"RT ( A/�\�-, ` ` � I \�J�"l t v \�� i �a� i DUE TO,OH AS A CONSEOUENCE OF: �� Mbrval bsiwasn onset antl aeam i ' R� t i i °:� �DUE TQ OR AS A CONSEOUENCE OF: � � � � � i Intervai between ons��M aeam_ �.1 -�q � �..�rvPU c -_ .... . .. . i__ - -'- - �. ._ _. _. '-_kl = - . - 1.�. - . .- i P�TOTHER SIGNIFICANT CONDITIONS-Cond'qions contrOutlrp Op tl�9 tleath Dul ral relateC PART MI IF MALE.W THERE A AUTOPSV ?/WAS CASE REFERRED TO MEDICAL N PREG W THE T 3 MONTHS? \E%AMINER OR CORONER� �Agss 10-5�) Vp No Yes No Yes Np �. 28b.DATE OF INJURV /MO..Oay.Yi.J 26t FIOUR OF IWURV ZBQ DESCWBE 1pW Iry,p/RY OCCURRED � AeeiderM � Undatermined M � SuicMa � PgMirg 280.INJURV AT WpRK 261.PLACE OF I�W,�pY%�lt Iqmg,farm.streM,laCbry 28g.LOCATION S7REET OR R.F.D.NO. CITV Oq TOWN STA7E ❑ ❑ ❑ dfic buildi s�eary� Homicide Invesugatron V� � .DATE Of D,E�ATH /Ab.Day.YcJ � 2Ba.DATE SIGNED /MO..OaY✓U 28D TIME OF DEATH �= 4�Id �/�� / ��= M �� .DATE SIGN /Mp..Qa Yr) �.TIME OF DEATH �g 2&.PRONQUNCED DEAD (MO..Day,YrJ 26p.PRONOUNCED DEAD /Fbuil � � � 8' � 3 , 30 �-�( M ��`� 8 M �uus�els�rod Y k�bEge.Aeath oecu retl at IM Gme.Eale aM daee arW die ro�Ix �� 2Be.On ihe basia d examinalbn an0ia' �a� .in my oqnbn Ceatl�oecurred at Me time.Eate and W�e anC tlue the ca �sta�eA. (S�naNre an0 Title► � �ry��T� � .DID TOBACCO USE CONTRIBUTE T ME�EA . - 30 HAS ORGAN OH TSSUE OONATION BEEN CONSIOERED? A NT NT � � VES � 'NO � � UNKNO � YES �"�O � NO Y�-' 31.NAME AND ADDRESS OF CERTIFIER(PHYSICUN, ER'SIPMVSICMN OR CWNTY ATTORNEYI lTypspPiirM/ S� 32a.REGISTRAR 32b.DATE FILED BV REGISiRAR /Ab.,Day.Yr./ FEB� , 1