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� f� 'm*+ 2 D fTS <br /> c m �, . _ <br /> G �' � � z n = � � cn � <br /> � m �r, o '� cn ca � �° � <br /> �a � � � 'i- � � _:.. z � �� 'Q- <br /> � rn � � rn ,� y <br /> � � •`� c, -� o <br /> O � � � <br /> � V� � N -rt Z �„�a ,.y,i„ <br /> (� s rn � <br /> - � � � -p p. ao O <br /> � m � r' � � CD <br /> � r� � r v <br /> � � V' � � � � Z <br /> � <br /> � � �� a cn o <br /> � ...�.. <br /> � �n c� <br /> p� � cn <br /> o � 9S � 07793 = <br /> WHEN THS CQPY CARftI�S TF�E RAISED SEAL OF THE NEBRA3KA.HEALTH AND_F�UI�(�RVICES � <br /> SYSTEII�IT C�RT�S TFIE BELOW TO BE A TRUE COPY OF THE OR/GINAL��TH � <br /> THE NEBRASKA HEALTH AND HUMAN SERNICES SYSTEM,V/TAL STAT/3���91 i��/S <br /> THE LEQAL DEPOSITORY FOR VITAL RECORDS - ��,�'K y�--� ; <br /> DATE OF/SSUANCE 9 9 10 7 7 9 3 =_� -_=���_ <br /> JUN 41999 Ass��►,- �►�� <br /> UNCOLN,NEBRASKA HEALTH AND I�IMA�I ��E� <br /> STATE OF NEBRASKA-DEPAR1MENf OF f�AL1H AND HUMAN 5F�RYif�$�.§�ID�ppRT <br /> VffAL STATISTICS '- - =- - -- = <br /> CERTIFICATE OF DEATH -_��=:� <br /> 1.DECEDENT-NAME FIRST MIDDIE LAST 2.SEX �3.�ATE OF DEATH /MOnIh.Day Yead <br /> Robert William Wheeler Male May 29, 1999 <br /> 0.GTV AND STATE OF BIRTH /Bnot n US A..nama counlryl Sa.AGE-Last Birthday UNOER 1 VEAR UNDER 1 DAY 6.DATE OF BIRTH /MOnM.Day.Yea J <br /> Norfolk, Nebraska �v�s� 65 5b MOS I DAVS 5t HOURS M�NS July 3, 1933 <br /> 7.SOCIAL SECURTIV NUMBER Ba.PLACE OF DEATH <br /> MOSPITAL Inpalient OTHER Nurs�n Home <br />■ 507-34-6924 --- ❑ -_ ❑ 9 <br /> Bb.FAGUTV-Name /Hnolmsfilu�pn.9ivesNeelandnumberl � EROutpatient � Resbence <br />. <br /> 2306 South August ❑ �^ ❑ a^e�,s�,��� <br /> Bc C�1V TOWN OR LOCATION OF DEATH BA.INSIDE CITV LIMITS Be.COUNTV OP DEATH <br /> Grand Island, Nebraska YB5 � N� ❑ , Hal l _ _ <br /> a nea�uc�vGC-Si�i e 9��COpNTY -"�-�`-'�s-� -" gc.CI . N R L A tON 9tl.STREET AND NUMBER /InclWingZip Code/ 9e.INSIDE CITV LIMITS <br /> .lT <br /> Nebraska Hall Grand Island 2306 South August 68801 �es� No❑ � <br /> 10.RACE-(e.g.,Wh�e.01ack.American Indian. 11.ANCESTRV le.g..Italien.Mezican.German,etc� 12.n MARRIED ❑WIDOWED 13.NAME OF SPOUSE /d y�ile g/ve maiden name/ <br /> etc.l ISpecilyl ��7y, ISpeciryl �� b <br /> �Y�llte American NEVER DIVORCED �rolyn Nelson � <br /> MAR <br /> tda.USUAL OCCUPATION /Give kindd wak done yur�ing mosl 14b.KIND OF BUSINESS INDUSTRY 15.EDUCATION ISpeay only h�ghest gratle completed� � <br /> d workmg li/e.even d refired/ Elemen�ary r ondary 10-12) College It-a or 5•i "� <br /> Superintendent Island Su 1 Co. �tFi <br /> 16.FATHEP-NAME FIRST MIDDLE LAST 17.MOTHER fIRST MIDOLE MAIDEN SURNAME ['] <br /> T <br /> Muriel Wheeler Juanita Grove a. <br />' t8.WnS DECEASED EVER�N U.S.ARMED FORCES? 19a.iNFORMANT-NAME � <br /> �Ves.�w.o unk.�. pf yes.grve war 2M dales d Services) � <br /> Yes Kor an War 9-15-1953/9-14-195 Carolvn Wtieeler <br /> 19b.iNFORMANT MAILING ADDRESS iSTREET OR R.F.D.NO..CRV OR TOWN.STATE.21P� <br /> 2306 South August Grand Island, Nebraska 68801 <br /> 20.�EMBA R-SIGNAT E 8 CICE�'SF NO. #�y/L 21a.METHOD OF DISPOSITIONTb.DATc 21c.CEMETERV OR CAEMAtOFV-NAME <br /> � <br /> �a���a. ❑Removal June 2, 1999 Westlawn Memorial Park � <br /> 22a.FUNERAL HOME� AME e1tl.CEMETERY OR CREMATORV LOCATiON Cttv OR TOWN STATE � <br /> A fel-Butler-Geddes �Cremalion ❑o«�a„a, Grand Island, Nebraska <br /> 22b.FUNERAL HOME ADDRESS �STREET OR R.F.D NO..CITY OR TOWN.STATE,ZIP� <br /> 1123 West Second Street Grand Island, Nebraska 68801 <br /> 23. IMMEDIA7E CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR IaL Ibl.ANO(cp i Intervai between onse�and oeam <br /> PART <br /> � << `N��,7 �� � ar�. <br /> lal �� DUE TO.OR AS A CONSEQUENCE OF�. i Interval belween onsei arxf neaN <br /> i 00 ` <br />� Ibl � O \ <br /> DUE TO.OF AS A CnNSEOUFNCE OF� _ i :;-.;a�va�beh.ecn onsel a�u����+am Q 1 <br /> i fD <br /> � <br /> Icl i <br /> OTHEfi SIGNIFICANT CONDITIONS-Conditrons contriDWing to the death but nq relatetl PART tll If FEMALE.WAS TNERE A 24 AUTOPSV 25.WAS CASE REFERRED TO MEDICAL <br /> P"'AT PREGNANCY IN THE PAST 3 MONTHS� EXAMINER OR CORONER� � <br /> II <br /> (Aqes t0�5a) Ves No Ves No Ves No <br /> 26a 26b.DATE OF INJURV /MO..Day.Yc/ 26c.HOUR OF INJURV 26tl.DESCRBE HOW�NJURV OCCURRED � <br /> � AcatleM � Undeterm�ned M <br /> � Swude � PerWing 26e,iNJURV AT WORK 26t P�pCE QF.INJURY-At home.larm.sveei.lactory 26g.LOCA710N STREET OR RF.D NO. GTV OR TOWN STA7E <br /> � ❑ ❑ oXice bmlAing.etc. lSpeciy,� <br /> Hom,utle InvesUgaUOn Ves No <br />� 27a.DAiE OF DEATH /MO.Day YrJ 28a DA7E SIGNED /MO..Day v.l 28b TIME OF DEATH <br /> �_ � - q- (�q 1 ��= M <br /> ��i 27b.DATE SIGNED /Ab..Day.VrJ 27c.TIME OF DEAT $i� 28c.PRONOUNCED OEAD /Mo.Day,Vcl 28d.PRONOUNCED DEAD /HOU�� <br /> �� -I-F �'. 1� RM ����fi M <br /> �� g <br /> 27tl.To tne best of my krqwleCg a occu�e0 a me,qQQ///te d lat M due to t�e ��� 28e.On Ine basis ol ezammauon and�a mvesugatqn,in my opinwn tleath occurreG at <br /> causelsl sta�ed. (' c> a the ume.Oate and pace and aue to Me causels)rateC. <br /> 5�naWra aM Title � f \ S nature an0 Title � <br /> 2➢.q0 TOBACCO USE C NTRIBUTE 7HE DEATH? a MAS AN OR TISSUE DONAT BEEN CONSIDERED7 30.b WAS CONSENT GRANTED7 <br /> � YES � UNKNOWN � VES �NO � VES �NO <br /> 31.NAME AND AODRESS OF ERTIFIER IPHVSICIAN,CORONER'S PHYSICIAN OR COUNTV ATTORNEY� /Type a Prinl/ <br /> D r. D a v i d R. C o 1 a n 7 2 9 N o r h u s t e r Grand I s land, Nebraska 68803 <br /> 32a.REGISTRAR 32b.OATE PILED BV REGISTRAR (MO..Day.Yc/ <br /> . JUN 4 �ggg <br />