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WHEN INS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />12/2/2003 200408726 ANLEYS. COOPER <br />ASSISTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA - _ _ HEALTH AND HUMAN SERVICES SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH 03 13367 <br />- -- -' - --. <br />FAST MIDDLE LAST -- 5maije a DATE OF DEATH /ManM, ay. Yeaq <br />Arnold Albert Wiese November 22, 2003 <br />11 a. CITY AND STATE OF BIRTH M na in U.SA. Am Coun*yl Sa AGE - Last BW Way UNDER 1 YEAR DAY 0. DATE OF BMTH /Marn7. ay. Year/ <br />Alda, Nebraska ni1 89 5b. MOs. I DAYS MWS. <br />September 20, 1914 <br />7. SOCIAL SECURTIY NUMBER 6a PLACE OF DEATH <br />507 -12 -8309 s ?R�� kUW srs OTHER: NwWV Hwm <br />6b. FACILITY - Name /M not 40AA0&% pvw avea and rwnrW ER Oulpadera ® Rniwnce <br />1420 W. 6th St. Q DOA 06wfspcdyl <br />k. CITY. TOWN OR LOCATION OF DEATH 6d. INSIDE CRY LIMITS 86. COUNTY OF DEATH <br />Grand Island, Nebraska Ya ® No 0 Hall <br />fla RESIDENCE •STATE YC. COUNTY 6C. CRY. TOWN OR LOCATION " STREET AND NUMBER llnCkdrp Zp Cowl W. WSIOE CITY LOURS <br />Nebraska Hall Grand Island 1420 W. 6th St. 68801 Y. ® Nb ❑ <br />10. RACE • lap. Wniu. Btck. Amenew k d w. 11. ANCESTRY 16.q.. 6W WL MeaiearL Geerlarl elel 12 MARRIED Q WIDOWED <br />Z I& NAME OF SPOUSE /Y wile. pw meidan rwrt/ <br />elt.l lsoaUNl ISpee6Yl <br />White American NEVER DIVORCED Wilhelmina Hild <br />14. USUAL OCCUPATION IGIw knd o1 work ebrt A#jV moat tab. KIND OF BUSINESS INDUSTRY <br />W w&" Aft awn Y rearadl - ... 15. EDUCATION (Specify onty sl races oewi <br />Pia:it Superintendent Dair EtntntryorSecoway 10- 121 Cosepe Ilea «s -i <br />16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />Herman wies Hennin s <br />IS. WAS DECEASED EVER IN U.S. ARMED FORCES7 WWII 16a WFORMANT -NAME <br />(Yea no. or �1 Ib yea piw war and data N Wervleeq <br />Yes ISept. 23; 19. /Dec. 20, 1945 Wilhelmina Wiese <br />19b. INFORMANT MU ADDRESS ISTREET OR R.F.D. N0. CRY OR TOWN. STATE 21% <br />1420 W. 6th St., Grand Island Nebraska 68801 <br />20_ E r IENSE 2/a METHOD OF DLSPOSITION 210. GATE 2t c. CEMETERY OR CREMATORY NAME <br />FUNME •NAME #1071 ® Burial [] Removal Z 25 2003 MF3rrlrci al p <br />21d CEMETERY OR CREMATORY LOCATION CRY OR TOWN STATE <br />All Faiths Funeral Home Cr. � oo< <br />22b. FUNERAL HOME ADDRESS (STREET ORRF.0. NO- CITY OR TOWN. STATE 23P( Grand Island Nebraska <br />2929 S. Locust St., Grand Island, Nebraska 68801 <br />23' PART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR W Ibl, AND (cp I <br />Werval between onel and dean <br />I I <br />(al Pneumonia <br />DUE TO, OR AS A CONSEQUENCE OF 1 As <br />I W Wval beftfom oriel am bean <br />(bi Small Bwel r <br />DUE TO, OR AS A CONSEQUENCE OF: I <br />Wmal be~ onr wo wam <br />IC) Adhesions <br />OTHER SIGNIFICANT CQN'T'ONs - Conditions <br />PART wn p b Mt d"Ih but not rNatd PART W IF FEMALE WAS THERE A Za AUTOPSY 20. WAS REFERRED TO MEDICAL <br />e PREGNANCY W THE PAST 3 MONTH$7 EXAMINER RE CORONER? <br />CHF Renal Cancer (Age* 10-541 Ya No Yw No Y. No <br />26a 26b. DATE OF INJURY /Mg., ay. Yr./ 26C. HOUR OF INJURY 26d DESCRIBE NOW MLi.JRY OCCURRED <br />❑ ACCO" ❑ Uwelermineo <br />❑ Saab, Penal 26e. INJURY AT WORK 26L PLAN INJURY - lerrrl. Waal <br />❑ dFCe 4p etc. ( p.V Z;; 2ft LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />❑ HprYeiEe mvesegation Yes � NO <br />27a DATE OF DEATH IMO.. ay. Yrl <br />2Ba DATE -ZNED (Ma, ay. Yrl 26b TIME OF DEATH <br />a1 November 22 2003 <br />€ y 27b. GATE SIGNED (Ab ay. vr) 27c. TIME OF DEATH 26C. PRONOUNCED DEAD fMO ay' Yrl . 25d PRONOUNCED DEAD (NIe✓I M <br />November 25, 2003 ` <br />E M s <br />27- Tome best d my W1o`rtope. watll ocCUrrod a16t brit, and DLWG and dlt b 6t M. <br />causNSl sated b 12b 6t arrt. daleWt and due b tl��� n my opWOn dean oCarrad al <br />IS nua and Title ► <br />cauaNsl Waled <br />29 DID TOBACCO USE CONTRIBU 0 TAE DEATHZ a arW Title <br />36a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30b WAS CONSENT GRANTED? <br />YES ® NO UNKNOWN I] YES ® NO 11 YES n NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICLW OR COUNTY ATTORNEYI (Typ oY f}„p �J <br />Larry Hansen M.D. 3016 W. Faidley Ave., Grand Island, Nebraska - 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR p,.., ay. Yr./ <br />DEC -1 2003 <br />n v - - - <br />I, Dan Naranjo certify that this a true and accurate copy of the <br />death certificate of Arnold Wiese. <br />Dan Naranjo <br />