|
I
<br />�u
<br />71
<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE QEBRASK(A HEALTH AND,
<br />SYSTEM, IT CERTIFIES TFE BELOW TO BE A TRUE COPY OF THE ORIGINAL
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/"
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS r
<br />DATE OF ISSUANCE 200312704 4, -z -2 ft�z�az___
<br />DEC 151998 AssTrs
<br />LINCOLN, NEBRASKA HEALTH AND tkw-AkS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERiEECE- SU
<br />VITAL STATISTICS -
<br />rRR TTPTr a TR nF n>~ a TLI
<br />I. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Monts. Day. Yw0
<br />Hilmer Everett Wallin
<br />male
<br />December 11, 1998
<br />4
<br />cn
<br />UNDER 1 YEAR
<br />c
<br />S. DATE OF BIRTH /M10FA Day. Year/
<br />MOS. DAYS
<br />I
<br />C
<br />n S
<br />(Yrs.) 5b.
<br />90
<br />March 23, 1908
<br />7. SOCIAL SECURTIY NUMBER
<br />Z -a
<br />N
<br />-s
<br />CD
<br />❑ ER Ou Baba e ❑ Residence ,
<br />z
<br />a Ste Francis Medical Center
<br />❑ DOA ❑ Other ISDectfyl
<br />��.
<br />171
<br />mo
<br />O
<br />Q.
<br />f7
<br />ga. RESIDENCE - STATE
<br />9b. COUNTY
<br />gc. CITY. TOWN OR LOCATION
<br />�
<br />ge: INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1124 S. Cherry St. 68801
<br />M
<br />D
<br />cn
<br />12. ® MARRIED ❑ WIDOWED
<br />o
<br />atc.11Speciry) white
<br />w
<br />z
<br />113.NAMOFSPWSE
<br />Ema Ellen Hanni
<br />(n
<br />16. EDUCATION (Specey prey grWe conlp4ndl
<br />E -.-. -y o, Secondary 10.121 CONaga It -4 or 5•I
<br />farmer ul
<br />16. FATHER - NAME FIRST MIDDLE UST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Isadore Frederick Wallin
<br />Selma Nyberg
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME
<br />(Yes. no. �r unk.)
<br />7C
<br />=
<br />- -- Ellen Wallin
<br />190. INFORMANT MAILING ADDRESS (STREET OR RF.O. NO.. CITY OR TOWN. STATE, ZIP(
<br />c7t
<br />i �
<br />2t a. METHOD OF 6,09TON
<br />s M
<br />CEMETERY OR CREMATORY NAME
<br />can
<br />® Burlaf ❑ Removal
<br />14 1998
<br />Elmwood Cemetery
<br />22a FUNERAL HOME NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />❑ C.I.A. ❑ Donation
<br />Rural Route St. Paul Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE, ZIP)
<br />1507 17th St. , Central City, Nebraska 68826
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR let. Ibl. AND (c)I I Interval belwaen onset and death
<br />PART �,_•
<br />I
<br />/� )
<br />lal �L
<br />3
<br />(b)
<br />I
<br />DUE TO. OR AS A C N OUENCE OF Inklmal between onset and death
<br />I
<br />2
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contriblaing b the death but not related PART
<br />PART /l
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />Q
<br />IN THE PAST 3 MONTHS?
<br />T- D
<br />N
<br />10 -541 Yes No
<br />Yes No }(
<br />Yea No
<br />26
<br />226b. DATE OF RDURY (Mo. Day. Yr.)
<br />Cn
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Acc-dent Undelemnetl
<br />3
<br />M
<br />Su-nd Pending
<br />26e. INJURY AT WORK
<br />GJ
<br />;:K
<br />Honi -Je Invesugaton
<br />CD
<br />27a. DATE OF DEATH IMo, Day Yrf
<br />28a. DATE SIGNED (Mo., Day YrI
<br />28b. TIME OF DEATH
<br />n
<br />O
<br />sys
<br />M
<br />y✓,
<br />`�i' g
<br />27b DATE S ED re .. Day Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMo. Day. Yr.)
<br />28d. PRONOUNCED DEAD /Howl
<br />• 4%_ �� d
<br />1335 P M
<br />M
<br />a
<br />°
<br />N
<br />to
<br />c
<br />Z
<br />causels) stated. J'/
<br />v 6
<br />the lime. date and piece and due b the causes) stated.
<br />,signature and Title A4
<br />Cn
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0
<br />WAS CONSENT GRANTED?
<br />129
<br />E:] YES NO ❑ UNKNOWN
<br />YES [V NO
<br />1:1 YES
<br />NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Print
<br />Dr. Richard M. Pruehlinci, MD 2116 W Faidle #400 Grand Island NE 68803
<br />32a. REGISTRAR /
<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE QEBRASK(A HEALTH AND,
<br />SYSTEM, IT CERTIFIES TFE BELOW TO BE A TRUE COPY OF THE ORIGINAL
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/"
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS r
<br />DATE OF ISSUANCE 200312704 4, -z -2 ft�z�az___
<br />DEC 151998 AssTrs
<br />LINCOLN, NEBRASKA HEALTH AND tkw-AkS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERiEECE- SU
<br />VITAL STATISTICS -
<br />rRR TTPTr a TR nF n>~ a TLI
<br />I. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Monts. Day. Yw0
<br />Hilmer Everett Wallin
<br />male
<br />December 11, 1998
<br />4. CITY AND STATE OF BIRTH /snot n USA.. name country)
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />S. DATE OF BIRTH /M10FA Day. Year/
<br />MOS. DAYS
<br />I
<br />5c. HOURS' MINS.
<br />Hordville, Nebraska
<br />(Yrs.) 5b.
<br />90
<br />March 23, 1908
<br />7. SOCIAL SECURTIY NUMBER
<br />Sa. PLACE OF DEATH
<br />506 -46 -8868
<br />HOSPRAL: ® Inpatient OTHER. Nursing Home
<br />❑ ER Ou Baba e ❑ Residence ,
<br />FACILITY - Nam fdnof utaMlrMon, give street and number/
<br />a Ste Francis Medical Center
<br />❑ DOA ❑ Other ISDectfyl
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />fie. COUNTY OF DEATH
<br />Grand Island
<br />I • yes &] No ❑
<br />I Hall
<br />ga. RESIDENCE - STATE
<br />9b. COUNTY
<br />gc. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /fnckaanpTjp Codel
<br />ge: INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1124 S. Cherry St. 68801
<br />Yee ® No ❑
<br />75- - (e.g., White. -Black. American Indian.
<br />11. ANCESTRY (e.g.. NOW, Mexican, German, at)
<br />12. ® MARRIED ❑ WIDOWED
<br />/M woe. A+ nuftn rMmel
<br />atc.11Speciry) white
<br />(Specdyl T,�,„iCaTl
<br />[�me
<br />NEVER DIVORCED
<br />113.NAMOFSPWSE
<br />Ema Ellen Hanni
<br />14a. USUAL OCCUPATION IGrve kind of work dare oWvg most lab. KIND OF BUSINESS INDUSTRY
<br />of workmg Me. even it refired)
<br />16. EDUCATION (Specey prey grWe conlp4ndl
<br />E -.-. -y o, Secondary 10.121 CONaga It -4 or 5•I
<br />farmer ul
<br />16. FATHER - NAME FIRST MIDDLE UST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Isadore Frederick Wallin
<br />Selma Nyberg
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME
<br />(Yes. no. �r unk.)
<br />lit yes. give war and dales of san iceal
<br />n
<br />- -- Ellen Wallin
<br />190. INFORMANT MAILING ADDRESS (STREET OR RF.O. NO.. CITY OR TOWN. STATE, ZIP(
<br />1
<br />20. EMBALMER - SIGNATURE d LICENSE NO.
<br />2t a. METHOD OF 6,09TON
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />/1 J
<br />® Burlaf ❑ Removal
<br />14 1998
<br />Elmwood Cemetery
<br />22a FUNERAL HOME NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />❑ C.I.A. ❑ Donation
<br />Rural Route St. Paul Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE, ZIP)
<br />1507 17th St. , Central City, Nebraska 68826
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR let. Ibl. AND (c)I I Interval belwaen onset and death
<br />PART �,_•
<br />I
<br />/� )
<br />lal �L
<br />1 DUE T0.0 AS A CONSEQUENCE OF �� �� � �� � i kesrvN between onaM and death
<br />(b)
<br />I
<br />DUE TO. OR AS A C N OUENCE OF Inklmal between onset and death
<br />I
<br />(c)
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contriblaing b the death but not related PART
<br />PART /l
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />11 / a �J� �D A PREGNANCY
<br />i /K�, o
<br />IN THE PAST 3 MONTHS?
<br />EXAMNER OR CORONER?
<br />fs (Ages
<br />10 -541 Yes No
<br />Yes No }(
<br />Yea No
<br />26
<br />226b. DATE OF RDURY (Mo. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Acc-dent Undelemnetl
<br />M
<br />Su-nd Pending
<br />26e. INJURY AT WORK
<br />26f. PLACE OFD INJURY ;(u , farm. street. factory
<br />d6c build SPec
<br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Honi -Je Invesugaton
<br />Yes ❑ No ❑
<br />27a. DATE OF DEATH IMo, Day Yrf
<br />28a. DATE SIGNED (Mo., Day YrI
<br />28b. TIME OF DEATH
<br />�<
<br />December 11 1998
<br />sys
<br />M
<br />y✓,
<br />`�i' g
<br />27b DATE S ED re .. Day Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMo. Day. Yr.)
<br />28d. PRONOUNCED DEAD /Howl
<br />• 4%_ �� d
<br />1335 P M
<br />M
<br />a
<br />°
<br />27d. To the best of my knowledge. tle occureretl at a* time, dab and place aril due to the
<br />28e. On me basis d examination an0,or nvestpalgn, m my opinion OsaM occurred at
<br />causels) stated. J'/
<br />v 6
<br />the lime. date and piece and due b the causes) stated.
<br />,signature and Title A4
<br />(Signature and Title
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />129
<br />E:] YES NO ❑ UNKNOWN
<br />YES [V NO
<br />1:1 YES
<br />NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Print
<br />Dr. Richard M. Pruehlinci, MD 2116 W Faidle #400 Grand Island NE 68803
<br />32a. REGISTRAR /
<br />32b. DATE FILED BY REGISTRAR fMa. Day. Yr)
<br />4 /✓A/
<br />DEC 15 1998
<br />Lot Fourteen (14), in Fonner View Subdivision, in the City of Grand Island, Hall County, Nebraska
<br />
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