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<br />8b. FACILITY-NAME (If nol In.tilullon, give .lreel end number)
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS 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 RECaRt;MN*-f'-~E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/~I'!fJIVt,-WHlf:Jf IS
<br />
<br />:::;:::~:::::~TORY FOR VITAL RECORDS. ~c{~~ ~#,~~}~,
<br />200600045 ~~'~R"
<br />AS9JSTANr=sTA~REbls7fRAFf
<br />LINCOLN, NEBRASKA HEAL'ljI'ANpHJ,!MANFllAy1tiEi:
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAN6~"J,N,Q,~~,~, RBI1~~6f ,,' _:13 '00 3 8
<br />CERTIFICATE OF DEATH 'H_ ' _-'-, ~ j.;l''"'=,'
<br />
<br />'~'e . ==; '~O; '~;~5 __I
<br />
<br />5c UNDER 1 DAY 6. DATE OF BIRTH (Mo.. Dey, Yr.) I
<br />HDURS MINS.
<br />January 18, 19201
<br />
<br />
<br />: ~:,:::~"'"' _ :::~:::: O_.~", I
<br />-I
<br />
<br />SEP 1.4 2005
<br />
<br />'"r;
<br />
<br />11
<br />
<br />
<br />DECEDENT'S-NAME (First. Midole, La'l,
<br />Dale Howard Willey
<br />
<br />~:::::;~~:~~;:~_::~:","m""""" r::':~"~" '""::T~:::'
<br />
<br />
<br />7. SOCIAL SECURITY NUMBER 6s_ PLACE OF DEATH
<br />505-14-1672
<br />
<br />Suffix)
<br />
<br />IJ.Q.SEill\l. :
<br />
<br />Riverside Lodge Retirement
<br />_______w.__......gouununi ty
<br />Be. cln OR TOWN OF DEATH Onclud. Zip Coo.)
<br />Grand Island, 68801
<br />
<br />ge.RESIDENCE-STATE ,~ 9b.COUNTY
<br />Nebraska Hall
<br />-..---
<br />9d. STREET AND NUMBER
<br />404 Woodland DR
<br />
<br />U Ul'I 0 Olh.r (Spe"ily)
<br />
<br />~80 COUNTY OF DEATH
<br />Hall
<br />[ -..-',."..,.-..-----
<br />9c CITY OR TOWN
<br />Grand Island
<br />
<br />
<br />9f. ZIP CODE
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />DI YES 0 NO
<br />
<br />We. MARITAL STATUS AT TIME OF DEATH MMarried 0 Never Merrled 10b. NAME OF SPOUSE (Fir.t, Middle, L..I, sumx) If wil.. glv, maloen nem..
<br />
<br />o Married, bUI .ep.roled 0 Wioow.d 0 Divorced 0 Unknown
<br />
<br />Roberta wingert
<br />
<br />11. FATHER'S.NAME (Fir.l,
<br />Ward
<br />
<br />Middle,
<br />
<br />L.sl,
<br />Willey
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S.NAME (FirM,
<br />Myrtle
<br />
<br />Mioole,
<br />
<br />Maloen Surneme)
<br />Rose
<br />
<br />13. EVER IN U.S. ARMED FORCES? GIVjl del~. o[ iervie.1f y... Ha.INFORMANT-NAME
<br />Nov b l.94::1 .
<br />(Yes,no,orunk,) Yes Dee 28, 194~ Roberta W11ley
<br />"-;5.':::~:OF DI~~:~::~~ ,/"' '1~~{'~GNATU~,/? 1 -- 118~ ~C~t~N::
<br />
<br />OCremallon 0 Enlombment 1Sd. CEMETERY, CREMAT Y OR OTHER LOCATION CITY fTOWN
<br />OR.movol o Oihar (Specify) Westlawn Memorial Park CemetSl:Jand Island
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16e. DATE (Mo_, Day, Yr. )
<br />Sep 9, 2005
<br />
<br />PART I. Enler Ihe chAin nl.v.nl.--oi.seses, inJuries, or compllcellonsnthal direelly c.uaao tha oeath. DO NOT eoier termlnalevaols .uch es esroiae .rrast,
<br />respiralory err est, or venlrlculAr IIbrlllalfon wllhoul.howlng the ellology. DO NOT ABBREVIATE, Enler only one eeu.e on allna. Ado adolllonAlllnes if necessery.
<br />
<br />(1~)M_E_Zll.a, A.~,_A_.U, SE: " ' .2 ".
<br />
<br />IMMEDIATE CAUSE (Fino' ,/v_.ettdt~..Qa/1'e~
<br />dl.....oreondftlonr..ultlng DUE TO, OR AS A Ce
<br />in deelh)
<br />
<br />Sequenliolly II.. conditions, If (b)
<br />any, I..dlng lolhe ceu.. listed DUE TO, OR AS A CONSEOUENCE OF:
<br />on IIn. e.
<br />En1erthe UNDER~YINCl CAUSE
<br />(oiseese or Injury thellnllisted (c)
<br />theevents...aultlngln d.olh) . OUE TO, OR AS A CONSEQUENCE OF:
<br />LASr
<br />
<br />
<br />STArE
<br />
<br />17e, FUNERAL HOME NAME ANO MAILING ADDRESS (SIr..I, City or Town, Slate)
<br />Curran Funeral Chapel 3005 South Locust
<br />
<br />on..I 10 oealh
<br />\"-:'
<br />~_t~_~btlg/J .
<br />
<br />onset to death
<br />
<br />onsello d..lh
<br />
<br />onset 10 death
<br />
<br />(d)
<br />
<br />1i\ART II OTHER SIGNIFICANT CONDITtONS.ConOilions ccnlnbullng to Ihe deelh bUI not r.,ull,ng in Ih. unoerlylng CAu.a glvan in PART I. 19, WAS MEDICAL EXAMINER
<br />
<br />1~X-~~'1/ f€.~' : f4{y:~}, ~)fjC- Jl:x:! ~~~c -' et,J;/- ___ ~ ~~:ONER~D::ACTED? I
<br />
<br />20. IF FEMALE: 21. MANNER OF DEATH 21 b.IFTRANSPORTATION INJURY 2~ WAS AN AUTO~SY-PERFORMEO:;---l
<br />.Ni!1ural 0 Homicide ODrlverlOpelator
<br />o Not pregnAnt wllhin past ycar 0 YES II: NO
<br />
<br />o Pr.gnsnl.t lima 01 oeeth 0 AcoldentO P.ndlng Inv..llgallon 0 P....nger ____...._ ____.____...
<br />o Pedes\;ien
<br />o Nol pregnsnl, but pregnant wllhln 42 oays of o.al~ 0 Suicide 0 Coulo nol be oslarmlned 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Olhsr (Speoify) I
<br />o Not prognsnl, bUI pregnenl43 deys 10 1 yeer belora daelh COMPLETE CAUSE OF OEATH?
<br />
<br />U Unknown if pregnanl wllhln Ihe pa.l ye.r 0 YES 0 NO I
<br />
<br />22a. OATE OF INJURY (Mo" Dey, Yr.) 22~~'PlACE OF INJURY-AI home, farm, ;;r.:i-,aC'Ory, olllce building, constr"ollon .ile, sIc. (S~~~~---".-..
<br />
<br />
<br />
<br />'.UJ
<br />
<br />I
<br />I
<br />
<br />24e. DATE SIGNEO IMo., Dey, Yr.) Nb.TIME OF OEATH -.\
<br />
<br />
<br />~. """''''"'" "" I~, ,,", "I ". "" ""'OO~"~ m ,u---1
<br />m
<br />
<br />22d, INJURY ATWORK?'----j--;;s. D,ES"C, RIBEHOW INJURY OCCURRED
<br />DYES 0 NO
<br />22f.lOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />
<br />CrTYlTOWN
<br />
<br />ST.'JE
<br />
<br />ZIP COOE
<br />
<br />23e, DATE OF DEAHl (Mo., Dey, Yr.)
<br />September 5,2005
<br />
<br />m
<br />
<br />z).
<br />~~!l!
<br />ig!'"
<br />c.f~~
<br />E~CI)?:z
<br />8llizO
<br />llz::>
<br />00
<br />~a:U
<br />815
<br />
<br />24a, On the ha~l~ 01 examination andfof invest!gallon, It, my opInion doath occurred at
<br />th.llme, oale .nd plAce and oue 10 t~. ceu.e(.) .laIM. (SlgnelUre ano Tille) l'
<br />
<br />25. DIDTOBACCo'u,60NTRIBUTETOTHE OEAT 260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />DYES 4:r NO U PROBABLY iIlJUNKNOWN 0 YES M NO
<br />27, NAME, TITLE ANIl'ADDRESS OF CERTIFIER (PHYSICIAN:C;()RONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ--' or print)
<br />John A. Wagoner BOO ~pha St., Grand Island, 68B03
<br />
<br />2Sb. WAS CONSENT GRANTEO?
<br />NoI Applicabl~.1I26e i. NO 0 YES ri. NO
<br />
<br />28., REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FllEO BY REGISTRAR (Mo., Dey, Yr.)
<br />
<br />SEP 1 2 2005
<br />
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