200406348 - Laserfiche WebLink

Browse

Rev 11/97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN sE "'s'ANCE AND K"mT2 0 0 4 0 6 3 4 8 VITAL STATISTICS CERTIFICATE OF DEATH z w 0 w 0 W 0 . LL 0. Lu Q ZI 0`5 Cl) � o r h i hk&K"ir)- F�j I fic ?w E&, �Jc &M -t' 1 32a REGISTRAR I 32b. DATE FILED BY REGISTRAR AIAx. Day VU FOR VITAL STATISTICS USE ONLY Place....................... A ................................ 8 ................................ C ................................ D ................................ E ................................ Part Ii ...................... TMV........................... NSC........................................................................................................................................................................................... ............................... .........................Census Tract No. Work........................................................................................................................................................................................................................................................... ............................... UC........................................................................................................................................................................................................................... ............................... Reject................................................................................................................................................................................................................... ............................... 0 Printed with toy Ink en reoycted paper e a� 1. DECEDENT - NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF OMTH /Mom" Dry VNy Fred LeRoy Wilsey Sr. Male I January 7 1999 e. CITY AND STATE OF BIRTH 11 nd h US A,. Mme courtkyl 58 . AGE - Lost Birthday I UNDER 1 YEAR UNDER I DAY 6. DATE OF BIRTH fAllori t Dry. 1. MOS. DAYS x. HOURS' MINS. Lexington, Nebraska (Ural Sb 78 March 21, 1920 7. SOCIAL SECURTIY NUMBER N. PLACE OF DEATH 506 -18 -9458 HDSPITAL. © Inpadenl OTHER ❑ Nurti 1. a ❑ ER OutpMIrM ❑ RNdann BD FACILITY - Name fM rldf m#ft4&t, 0/1''e S~ and ntnnber/ Saint Francie Medical Center ❑ DOA ❑ DOW (w *1 Be . CITY. TOWN OR LOCATION OF DEATH 6d. INSIDE CITY LIMITS M. COUNTY OF MTN Grand Island I Yes ® No ❑ Hall 9a. RESIDENCE - STATE Bb COUNTY 9c. CITY. TOWN OR LOCATION Bd. STREET AND NUMBER 1#&Ayp Zlo Coat) INSIDE CRY LIMITS Nebraska Hall Grand Island 1007 W. 8th 68801-7 yea ® No[] 10 RACE - N.p., White. Black. American Wien 11. ANCESTRY leg_ NaNan. Me■¢an. German, ekl f 2. ® MARRIED E] MARRIED tow*.. gW M& tfln Aw"t1 eklfSoacdy) White (Specify) American I NEVER DIVORCED 111NAMEOFSPOUSE Velma R. Sanders 14. USUAL OCCUPATION IOrve kind of cork date du1h9 me w 14b KIND OF BUSINESS INDUSTRY S. EDUCATION (Spec of INlrketg No, ow f / refired) Repairman Appliance Re air Ebmentary a 12( CdUW II •a a 5• I 12th (fe IS. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME e Leon NMN Wilsey Lela- NMN Collins 16 WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yea. no. or unk.) IN yes. "war and dates of eervlceeI Yes WWII 1 -31- 42/2 -8 -46 Velma R. Wilsey 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. 21P) 1007 W. 8th, Grand Island, Ne. 68801 BALMER • SIGNATURE 8 LICENSE NO #1/43 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME R &,,% � ❑X Burial El Removal Jan. 11 1999 Westlawn Memorial Park 22a FUNERAL HOME -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston - Sondermann F.H. ❑ °r"n"°n ❑°OneM1" Grand Island, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN, STATE, 21P) 601 N. Webb Road, Grand Island, Ne. 68803 -4050 23. IMM BATE CAUSEEn1 (ENTER ONLY( ONE CAUSE PER LINE (a). lbbll, AND (c)) I Nrarvel batrrean anti PART DFOR fA lr� DUE TO, OR AS A C (*SEOUENCE OF I Interval batman on M and death I (b) DUE TO, OR AS A CONSEOUENCE OF I Naarval Oaleraan gnaw and cream I (c) 1 I PART OTHER SIGNIFICANT CONDITIONS - Cordkions contributing to the death but not related PART III IF FEMALE. WAS THERE A 25. WAS CASE REFERRED TO MEDICAL PREGNANCY 1,�_AUTOPISY IN THE PAST 3 MONTH87 EX AMINER OR COAD14EPI (Apse 10 -Se) VM ND yea NO Y. No 268. 28b. DATE OF INJURY fW,, Day. Yr/ 28c. HOUR OF INJURY DESCRIBE HOW INJURY OCCURRED Attident � Undetermined - 126d. M Suicide PeMinq 26e. INJURY AT WORK 281. PLAa E I INJ„c ;At hople, farm. Sheet. factory oIIM1N bu s08cMf 26g. LOCATION STREET OR R.F.O. NO. CRY OR TOWN STATE ElHomicide Investigation Yes[:] No ❑ 27a. DATE OF DEATH fMo. Day Yrl 28a. DATE SIGNED /Ab. Day yrI 28b TIME OF DEATH M ° 6 E 27b. DATE SEED 1Ab. Day. rr/ 27c TIME OF DEATH 28c. PRONOUNCED DEAD fAolo. Dry. Yrl 280. PRONOUNCED OEAD N'at /1 11 Rq � �� M 9 M E 1 27d To Mel d my k . death occur el the tlme, dab sand due to the 2M. On Bb W W of eSarrMnNion aM� a InvsMlpaBOn, in my bptrNOn dwlN odarrad M . uetrtlel Sleled. s the time. dab and place and due b f couaMe) Mabd. I and and TIM DID TOBACCO USE CON? IBUTE TO THE EATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? 129 El YES NO UNKNOWN .� ❑ YES NO ❑ YES No � o r h i hk&K"ir)- F�j I fic ?w E&, �Jc &M -t' 1 32a REGISTRAR I 32b. DATE FILED BY REGISTRAR AIAx. Day VU FOR VITAL STATISTICS USE ONLY Place....................... A ................................ 8 ................................ C ................................ D ................................ E ................................ Part Ii ...................... TMV........................... NSC........................................................................................................................................................................................... ............................... .........................Census Tract No. Work........................................................................................................................................................................................................................................................... ............................... UC........................................................................................................................................................................................................................... ............................... Reject................................................................................................................................................................................................................... ............................... 0 Printed with toy Ink en reoycted paper e a�