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<br />WHEN THIS Copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERnFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL REIdJRf!JiNtI FILE WITH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TIS~--eCrll(ijj,Wff1.CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~i-:'~-"2'"",c.~fIt:.:~"c,_co. .-,-
<br />
<br />
<br />~;;';;~;~ ~2/1!a
<br />2006003 8~ A$SISTANT-STAT.E-RI;(i/~TRAR
<br />LINCOLN, NEBRASKA HEALTHAN~f~,fjRYt~J~r:1I'J'!'
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND IR1MANSE~VI~FlN~AND SUl'J'ORT
<br />CERTI;r~S~~~~EATH"---":'f:',.'" :,~>:,.:.- . 04 146 7 3
<br />
<br />'- DE:C~Oe:NT - NAMe: FIRST MIOOle: LAST 2. S~X . - '3. OATe: OF O~TH IMonth. Day. Y""r)
<br />
<br />Darrell
<br />
<br />
<br />Leslie
<br />
<br />Wilhelm
<br />
<br />Sa, AGE - Last Bi<1l1day UNOe:R 1 V~R
<br />IV".I 50. MOS. DAVS
<br />69
<br />e.. PLACE OF OEA TH
<br />
<br />Male
<br />
<br />4. CITY AND STATE OF BIRTH III nDI in USA. nam. CDunlry/
<br />
<br />IMooth,Oay, Year)
<br />
<br />Athol, South Dakota
<br />7. SOCIAL SECURTIV NUMBER
<br />
<br />6 1935
<br />
<br />OTHE_~: 0" NurSing Home
<br />o Residence
<br />
<br />o Other (SpeC/IV!
<br />
<br />504-28-1034
<br />
<br /> HOSPITAL: ~ Inpa.ien1
<br /> 0 ~R Outp.tlent
<br /> 0 DOA
<br />8<1. INSIDE CITV LIMITS
<br />
<br />80. FACILITY - Name
<br />
<br />(H not institution, give street ana ntJmblJr)
<br />
<br />Bryan LGH East
<br />8c. CITV. TOWN OR LOCATION OF DEATH
<br />
<br />
<br />Lincoln
<br />
<br />8a. RESIDENCE. STATE
<br />
<br />
<br />1 S. ~DUCATION (Specify only hlghe.t grade comoleted)
<br />Elementary or sr2'ndary 10-121 Cmlege 11-4 or 5.1
<br />
<br />/Including Zip COde/ 9.. INSIOE CITV liMITS
<br />
<br />Yes [K] No 0
<br />13. NAME OF SPOUSE (If wife. give maiden name)
<br />
<br />Nebraska
<br />1 Q. ~ACE - {e,g., White, SlaCk, American Indian.
<br />.tc,IISpoClfyIWhite
<br />
<br />11. ANCESTRY (e.g" Italian, Mexican, German, ele)
<br />ISpeclfyl American
<br />
<br />Grace Durante
<br />
<br />14a. USUAL OCCUPATION (GIVe kind Of work <lOne C/J/'ing mO$I
<br />01 Wf}~mg life, eve" J~ retked!
<br />Welder
<br />
<br />Rail Road
<br />LAST
<br />
<br />MIDDLE
<br />
<br />MAIO~N SURNAM~
<br />
<br />16. FATHER. NAME
<br />
<br />FIRST
<br />
<br />
<br />Ke ler
<br />
<br />17. MOTHER
<br />
<br />MIDDLE
<br />
<br />Ralph
<br />
<br />Carroll
<br />
<br />Wilhelm
<br />
<br />18, WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />(Yes. no. or unk.) /If yes. give war and elates. of $ervice:s)
<br />Yes Korean Conflict 1951 - 1954 Grace Wilhelm
<br />190. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />
<br />
<br />210. DATE
<br />
<br />21c, CEMETERY OR CREMATORY NAME
<br />
<br />\1 ~<Q
<br />
<br />~ Bu"al 0 Removal 1-6-2005
<br />
<br />Grand Island City Cemetery
<br />
<br />21d. CEMETERV OR CREMATORV LOCATION
<br />
<br />GITY OR TOWN
<br />
<br />STATE
<br />
<br />All Faiths Funeral Home
<br />
<br />D Cremation 0 00/13110r'1
<br />
<br />Nebraska
<br />
<br />Grand Island
<br />
<br />220, FUNERAL HOM~ AOOR~SS
<br />
<br />(STREET OR R.F.D, NO.. CITY OR TOWN, STATE, ZIP)
<br />
<br />2929 S, Locust Street, Grand Islmld, NE 68801
<br />23. IMMEDIATE CAUSE I~NTe:R ONl v ONE CAUSE PER LINE FOR la), 10), AND (cll
<br />PART
<br />I
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />
<br />Ibl Cerebrovascular Disease :
<br />. riuE TO, OR AS A "'CONSEQUENce OF: -~-~-~~~w------~~-~--~--:-----'--'------'-~.-'T -~8'~en onsetand death-~
<br />I
<br />I
<br />I
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />
<br />No X
<br />
<br />Interval between onset and deatl1
<br />
<br />lal Large Brain stem Infarct.
<br />DuE TO, OR AS A CONSEOUENCE OF'
<br />
<br />Interval between onset and dealn
<br />
<br />lei Atherosclerosis
<br />t='AFl:T OTHER: SIGNIFICANT CONDITIONS - Conditions contributing to lhe death blll not related
<br />
<br />II Severe Coronary Artery Disease
<br />250. OA TE OF INJURV (Mo" Day. Yr.) 26c. HOUR OF INJURV
<br />
<br />26a.
<br />
<br />
<br />0 Accident 0 Unclelerrninad
<br />0 Suicide 0 Pending 28e, INJURY AT WORK
<br />0 Homicide InvestIgation Ye5D NoD
<br />
<br />STREET OR RFD. NO.
<br />
<br />CITY DR TOWN
<br />
<br />STATE
<br />
<br />26g, LOCATION
<br />
<br />27a. DATE OF DEATH iMo.. Ooy. Yr.}
<br />
<br />2ea. OA TE SIGNED (Mo" Doy. Yr.)
<br />
<br />280. TIME OF DEATH
<br />
<br />... ~z
<br />... -,,<<
<br />'.Ii ~
<br />'! !~~
<br />~H
<br />"I l- ~
<br />J
<br />
<br />December 31,
<br />
<br />2004
<br />
<br />M
<br />
<br />_" it;
<br />
<br />1.D ~ ti 280. ~RONOUNCED DEAD (Mo.. Oay, Yr.)
<br />~S~
<br />M 11 ffi ~ ~
<br />.27d. 10 the best of my knowledge, death oeeurrod at the lime. date and place and due 10 the ~ ~ u 28(t, On the baSis of examination and'or investigation, in my opinion deatn occurr~
<br /> at
<br />causelsl stated, s-: /. " .; I-r ~ 8 is the time. date and place aM due to the caU5ei$1 stated.
<br />
<br />I .lStqn~t~re and Title .... - M a Yl Ci.rf'tfl (SI nature and Tltlel ..
<br />-2if DID TOBACCO USE CONTRIBUTE TO THE DEATH? 3D,a HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREO?
<br />
<br />o Y~S 0 NO [i] UNKNOWN 0 YES IKJ NO
<br />
<br />27c. TIME OF OEATH
<br />
<br />28d, PRONOUNC~O O~AD (HOUri
<br />
<br />2?0. DATE SIGNED (Mo.. aey, YO
<br />
<br />I, /2-, 0 t-
<br />
<br />9:30 a.m.
<br />
<br />M
<br />
<br />30.0 WAS CONSENT GRANTED?
<br />o Y~S
<br />
<br />KJ NO
<br />
<br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIJ\N OR COUNTY ATTORNEYI tTy"" or Prinl)
<br />
<br />Sabyasacl1i Mahapatra, MD,
<br />32.. REGISTRAR
<br />
<br />
<br />320. DATEFILEOBVRJAN~ f.r ~005
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