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200311980 WHEN TINS COPY CAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMANL SERVICES SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REGDRt3 SWTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC986. � lG 1S THE LEGAL DEPOSITORY FOR VITAL RECORDS. `� O `� / gollawp =' AssI3 `sW devittRAh LINCOLN, NEBRASKA HEALTH AND HL*ATN $ERVICES-$Y rE* STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERV .0- 3&+WANCE AND SUMORT VITAL STATISTICS CERTIFICATE OF DEATH - -= - —— I DECEDENT NAME FIRST MIDDLE LAST 2 SEX - - - -_ 3 GATE OF DEATH lMonlh Dav Ye ail Thomas James Wagoner Male November 18, 2000 4 CITY AND STATE OF BIRTH /If nol in US d name country) DUE TO. OR AS A CONSEQUENCE OF 5a AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6 DATE OF BIRTH lMonlh. Day Year)) - - Wood River, Nebraska III IF FEMALE. WAS THERE A (Yr" 91 January 28, 1909 5b MOS DAYS 5c HOURS MINS 7 SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH (�(r�'i��. 506-18-5719 HOSPITAL ❑ Inpatient OTHER ❑ Nusmg Home 26. V 26b DATE OF INJURY (Mo. Day Yr.) El ER Outpatient Residence Ed FACILITY Name lllnol.nslifuhon. give 'tree" and number) 1 41 1 Walnut Street ❑ DOA ❑ Other l$pecaln Bc CITY TOWN OR LOCATION OF DEATH _n Bid INSIDE CITY LIMITS 8e COUNTY OF DEATH Wood River Swode Pending Yes [� No ❑ Hall 26g. LOCATION STREET OR R.F.D NO CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ o ice bui ing. etc lSpeciy/ 9a RESIDENCE STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d STREET AND NUMBER mcludcgF" ,R$ 79e INSIDE CITY LIMITS Nebraska Hall Wood River 1 41 1 Walnut Street I ® ❑ 27a DATE OF DEATH (Mo Day Yr) 28a DATE SIGNED (Mo. Day Yr) 28b TIME OF DEATH Yes No 10 RACE leg., While. Black American Indian 11. ANCESTRY le .g. Italian. Mexican. German, etc) 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE (If mfe . prve maiden name) etc ISToeciyl Wlll to /Specify) I rlsh NEVER DIVORCED MARRI Cecelia Burns 14a JSUAL OCCUPATION 1Grve kindof work done during moss Novembe 2 7, 2000 141, . KIND OF BUSINESS INDUSTRY 115 EDUCATION ISpec,ty only highest grade completed) of working A le. even it refuel) Farming S Agriculture M Elementary or fe2ndary 10 -12) College i 1 4 , GG _ 16 FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME t Arthur Lee Wagoner Kathryn Teresa Langan 18 WAS DECEASED EVER IN U.S. ARMED FORCES? 198 INFORMANT NAME (Yes no or unk I 111 yes q;ve war and dales of services) 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30 b WAS CONSENT GRANTED? ❑ YES NO ❑ UNKNOWN I NO NO Cecelia Wagoner NAME AND ADDRESS OF ERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or P—rp 19b INFORMANT MAILING ADDRESS (STREET OR ELF D. NO CITY OR TOWN. STATE. ZIP) Alpha 1411 Walnut Street Wood River, NE 68883 32a REGISTRAR - 20 E R SI NATURE 8f NSE NOf�� 32b. DATE FILFD �Y GISTRAR /�. ,Q3y� ryJ (V)U 21a METHOD OF DISPOSITION 21b DATE 121c CEME TERYORCREMATORY NAME - t�l{�J L`I e2� - - ®Burial ❑Remp�al 11 /22/2000 St Mary's Cemetery 22a FUNER HOME - NAME 21C CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE ❑Cremation ❑Locator, Wood River, Nebraska A fel Funeral Honme 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) P.O. Box 126 Wood River, Nebraska 68883 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ia: ibl. AND Icii PART lal Interval between onset and dearr, i !. DUE TO OR AS A CONSEQUENCE OF Interval between onset and dean �� Ibl I DUE TO. OR AS A CONSEQUENCE OF _ _ Interval between onset and oean Icl I I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL PA � PREGNANCY II IN THE PAST 3 MONTHS? EXAMINER OR CORONER? (�(r�'i��. (Ages 10 -54) Yes No Yes No Yes No 26. V 26b DATE OF INJURY (Mo. Day Yr.) 26c. HOUR OF INJURY 26d, DESCRIBE HOW INJURY OCCURRED Accdenl Undetermined 1 _n M Swode Pending 26e INJURY AT WORK 26f. PLACE QF INJURY - At home. [arm, street. factory 26g. LOCATION STREET OR R.F.D NO CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ o ice bui ing. etc lSpeciy/ 27a DATE OF DEATH (Mo Day Yr) 28a DATE SIGNED (Mo. Day Yr) 28b TIME OF DEATH - ` November 18,2000 <w >� z a M a 27b. DATE SIGNED (Mo. Day Yr 1 27c. TIME OF DEATH 28c PRONOUNCED DEAD (MO_ Day, Yr I 28tl. PRONOUNCED DEAD (Hour/ a Novembe 2 7, 2000 11:30 A _ ° S M ° ° ° M - a 27d To the best of m kno ge. death occurred at th time, date and place and due to the 28e On the basis of examination and or investgaton, In my opinion death occurred at caus'e151 slated. , the time. date and place and due to the causelsl staled. ISM nature and Ti ) ► � ISM nature and Title) ► 29 DID TOBACCO USE CO JIB TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30 b WAS CONSENT GRANTED? ❑ YES NO ❑ UNKNOWN ❑ YES NO ❑ YES ❑ NO NAME AND ADDRESS OF ERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or P—rp Alpha Grand Island,NE 68803 32a REGISTRAR - 32b. DATE FILFD �Y GISTRAR /�. ,Q3y� ryJ (V)U &t&f - - (! aS T