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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEA,4
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORI
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />DEC 11 2006
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES`FINA149E FJb' UPPO
<br />( QTIFICATF AF DFOTH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Terry Lee Wampole
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />Nov. 25, 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Jan . 16 , 1945
<br />Ord, Nebraska
<br />(Yrs.) 61
<br />MOS.
<br />DAYS
<br />.
<br />HOURS
<br />' MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />S 6 S - 6 _ 5 0 3,
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient MB C] Nursing HomeILTC O Hospice Facility
<br />❑ ER/Outpatient CXDeoedent'eHone
<br />❑ CO4 ❑ Otn.r(Spealfy)
<br />Bb. FACILITY -NAME (If not Institution, give street and number)
<br />427 Commanche Ave.
<br />Bc. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island, 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITYOR TOWN
<br />Grand Island
<br />ad. STREET AND NUMBER
<br />427 Commanche Ave.
<br />Se. APT. NO
<br />9f. ZIP CODE
<br />68803
<br />Sg.INSIDE CITY LIMITS
<br />X1 YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH jI Married ❑ Never Married
<br />❑ Married, but separated ❑Widowed CI Divorced ❑Unknown
<br />10b. NAME OF SPOUSE (Firstt, Middle, Last, Suffix) II wife, give maiden name.
<br />Jeanette Soper
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Donald Wamp le
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Doris Bac�gpr
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />(Yea, no, orunk.) No
<br />14a. INFORMANT -NAME
<br />Jeanette Wampole
<br />14b. RELATIONSHIP TO DECEDENT
<br />-Wife
<br />15. METHOD OF DISPOSITION
<br />❑Burial ❑Donation
<br />OCGromatlon ❑Entombment
<br />❑Removal ❑ Other (Specify)
<br />16a. EMBALMER.SIGNATURE
<br />not embalmed
<br />16b. LICENSE NO.
<br />tec. DATE (Mc., Day, Yr. )
<br />Nov.27, 2006
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Central Nebraska Cremation Service, Gibbon, NE
<br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State)
<br />nd Island, -NE
<br />All Faiths Funeral Home, 2929 S. Locust, GraIII
<br />17b. Zip Cods
<br />68801'
<br />to PART I. Enter the chefn of events --diseases, eludes, or complications --that directly caused the death. DO NOT enter termtnel events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without stowing the etiology. DO NOT ABBREVIATE. Enter only one cause on a fine. Add additional lines if necessary.
<br />IMMEDIATE CAUSE(Rnal
<br />disease or condition resulting
<br />In death)
<br />Sequentially list conditions, if (b)
<br />any, leading tothe cause naiad
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(dlseaeeorInjury that Initiated (c)
<br />theeveMa resulting in death)
<br />IMMEDIATE CAUSE: 11 ,
<br />4° 4 AV'r4,0lc (-A1144 ( 5G of
<br />DUE TO, OR AS A CONSEQUEE OF:
<br />A- - -'. MATE INTERVAL
<br />onestte death
<br />2-7 ear •
<br />onset to dee
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />DUE TO; OR AS A CONSEQUENCE OF:
<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 I.
<br />,
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />D YES X-NO
<br />nq
<br />t1
<br />p «
<br />20. IF FEMALE:
<br />Not pregnant within past year
<br />CI Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />P 9 Y
<br />CI Not pregnant, but pregnant 43 days to t year before death
<br />❑ Unknown It pregnant within the pest year
<br />21a. MANNER OF DEATH
<br />Ipaturei ❑Homicide
<br />❑ Accident❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b.IFTRANSPORTATION INJURY
<br />❑Driver/Operator
<br />❑Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c.WAS ANAUTOPSYPERFORMED?
<br />❑YES COO
<br />21d.WERE AUTOPSYFINDINGSAVAHA81-ETO
<br />COhIPLEIEGAUSEDEATH?
<br />0 YES 0 NO
<br />22e. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, term, street, factory, office building, construction site, etc. (Specify)
<br />s<1
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />4I's
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />1$1$1$
<br />t -
<br />To be completed by
<br />Attending PHYSICIAN
<br />ONLY
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />November 25, 2006
<br />t•
<br />=24c.PRONOUNCEDDEAD(Mo.,Day,Yr.)
<br />10.1>.m
<br />W
<br />. (
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />m
<br />24d.TIMEPRONOUNCEDDEAD
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />I1.27- ZOO
<br />23c. TIME OF DEATH
<br />4:30 p m
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred at
<br />the time, date end place and due to the ceuee(s) stated. (Signature and Title )
<br />23d.To the best of my knowledge, de occur ed at the time, date and place
<br />and due to cau state . Ignature and Tide) ♦
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEAT ?
<br />❑ YES CPO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES liC NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTATTORNEY) (Type or Print)
<br />Gary Settle, M.D. 2116 W. aidlev Ave.. Grand Island. IJE 6fl803
<br />ili),(�•
<br />28a.REGISTRAR'SSIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />NOV 2 8 2006
<br />
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