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<br />~UU7U6752 <br />STATE CK NE8RA5KA - DEFWrrMENT CK 1-EAlTl-l AI<<) HUMAN SERVICES FINNCE AND SUPPORT 32.1986 <br />CERTIFICATE OF DEATH <br /> <br />1. DECEDENTS.NAIlE (Flral. <br />'Mlliam Terrence Nester <br />.. CITY AND STATE 011 TEIIlIlTORY. 011 FOIIEI6N COUNTRY OF BIIITll <br /> <br />IIldtl1.. <br /> <br />U111, <br /> <br />suml) <br /> <br />2.5EX <br />Male <br /> <br />1 DATE OF DEATH 1110.. Drt, Y'.) <br />January 15. 2007 <br /> <br />.. DATE OF IIlTH (110.. Drt. Y'.) <br /> <br />V\IIchita. Kansas <br />T. SOCIAl. SEClJIIlTY NUlIllER <br />353-40 -4364 <br /> <br />eo <br />... PUCE OF DEATll <br /> <br />tKlllf1.TAI.: <br /> <br /> <br />11.1946 <br /> <br />51. AGE-Ln' B1",",,' Sb. UNDEII t YUII <br />lYra.) 1I0S. DAYS <br /> <br />Ii) In","nI <br /> <br />anIB a .......HomtATC aHDoP" F...., <br /> <br />81>. FACILITY.NAIlE (II nol ,ndllution. gI.. 1"..1 Ind numb.,) <br /> <br />a E~"nI <br /> <br />a~l_ <br /> <br />I <br />;! <br />; <br />~ <br />i <br />I <br />II <br />{!. <br /> <br />Nebraska Medical Center <br />lie. CITY 01\ TOWN OF DEATll ('-lip C....) <br /> <br />Omaha 68198 <br />1III.IIESlDENCE-STATE <br /> <br />aD <br /> <br />a Obf(8pdJ1 <br />8cl. COUNTY OF DEATH <br /> <br />Nebraska <br />lid. STREET AND NlMlER <br /> <br />2417 che Road <br />101. IIAIIITAL STATUS AT TillE OF DEATH Ii) 11._ aN..., Ill1ned <br /> <br />lib. COI.MY <br />Hall <br /> <br /> <br />It. ZIP CODE <br /> <br />",INSIOE CITY UIIITS <br /> <br />Ii YES a NO <br /> <br />68801 <br />lOll. NAIlE OF SPOUSE lFi'"t 111011", Lnl S....) II Will. ,.. .....on name. <br /> <br />Q lII,ned. buI H1>...IIG Q W_d Q OrvO<Old a u-.. <br /> <br />1I1U111 <br /> <br /> <br />Coleman <br /> <br />11. FATHEII'S.NAIIE (flra'. <br />William E Nester <br />13. EVER INU.S. ARIIED fORCES? Gmdllu"'''rvIOOlI",. <br />(Yu. no. 0'''.) No <br />15. IIETIlOD Of DlSPC$ITIOIl <br /> <br />111_. <br /> <br />LIII. <br /> <br />I Firat IIlddll. <br /> <br />IIlidon sum.....' <br /> <br />'.b. RELATIONSHIP TO DECEDENT <br /> <br />QDonI.... <br /> <br />leb. UCEq~-V <br /> <br />CITY I TOWN <br /> <br />'Mfe <br />IIC. DATE (110.. OIy. VI. ) <br />Ja.~!!l18. 2007 <br />STATE <br /> <br />Q ClllnlIOll a ~ <br />QR_ aOlhl'IS~1 <br /> <br />wesuawn ~l Park CemeteIy <br />171. fUNERALllOlIE NAIIE AND lIA1l1NG ADORESS I_L Clly d. T..... SIllII, <br /> <br />Gral'ld Islal'ld <br /> <br />Nebraska <br /> <br />1111. ZIp Codo <br /> <br /> <br />68801 <br /> <br />.. In,tructlons an nampl.. <br />18. PART I. EnII' IIlo _n of "_--dIU............. Or ~"_-"f ~~ _.. dOl'" DO ~T ...... Ie_ ....... ""'" n collllle IrIItl, <br />....101\' ...... 0' ....-, 1Ib"111on wllhoul_ng .. Ilo\ogy. DO NOT ABIIREVlATE. EnIIr any ... CO"" on Ih. Add odelIl_ _ iI_I\'. <br />"MEDIATE CAlISE; <br /> <br />APPfIllIlIIlATE INTERVAL <br /> <br />_lO_ <br /> <br />MEDlATlCAUllElfNl <br />--.--. <br />" ...... <br /> <br /> <br />.1 <br /> <br />n()W'1> <br /> <br />-.- <br /> <br />........., ..--.. <br />..,.-....- ..... <br />onhL <br />_Ill \JNDeI\.'tIIGCAIIlIfi <br />.-.. -..,. ......-- <br />.._-...,g..~ <br />UIIr <br /> <br />Dl ~iS <br />OIJE TO. OR ASA COHSEQUENCE OF: <br /> <br />IlAJUt <br /> <br />_lOdOI" <br /> <br />Ie) ){t \ <br /> <br /> <br />Ie.u..Lm I'(l. <br /> <br />I u..lU t <br /> <br />_!:> O!O!'" <br /> <br />(d) <br /> <br />18. PART II. OTllER SIGNIACANT CONOITION5-CondIlono conbtllulng to III _ tIUl nol ......Ing in fie underlying co_lIIV1n.n f'IUlT I. <br /> <br />Ie. WASIIEOICAl ElWIIIER <br />OR COAONER CONTACTED? <br />a YES ~ NO <br /> <br />a: <br /> <br />E <br />III <br />CJ <br />j <br /> <br />I <br />.. <br />~ <br /> <br />20. IF FEMALE' <br />o NoI p..",.,1 willin ","I Y"" <br />D Pr~nl.ll... of dOl" <br />a NoI pralln.nl. tIUl Pravnont wlflIn.2 dlYI 01 dol.. <br />a Not ~ tIUlllllgl1ln\ 43 dlyato I Y.' bolOfl dOl.. <br />Q U'*nown ilprapnlWllin III pod"" <br /> <br />21..IIANNER OF DEATH <br />l(NoIlnl Q- <br /> <br />Q A<Ci<lonlQ P_ng _lgIIlon <br /> <br />Q SlladO aColJanotllOdoll_ <br /> <br />21b.IF TRANSPOIITATION IN.AJRY <br />Q DnvOflOporltor <br /> <br />a PaI_ <br /> <br />a __ <br /> <br />a 0", ($pIaly) <br /> <br />21e. WAS AN AIITOPSY PERFORIIED? <br />a YES \(NO <br /> <br />214 WERE AlIlOPSY RIIllNG$ AV AlLAIl.E TO <br />COIIPlETE CAl.ISE OF DEAJM7 <br />a YES CJ NO <br /> <br />o ~~:" Q,~':'!:\ <br /> <br /> <br />221. DATE OF INJURY (110.. DIy. Y'.l <br /> <br />2211. TillE Of INJURY 22<. PLACE OF INJURY.AI homo. linn. .-. -'Y. _1IIII$lQ. ",,",11UC1on alII. 01.. (Spoafy) <br />rn <br /> <br />224 INJURY AT WOIIK? <br /> <br />22'-LOCA~ OF IIUJRY . STREET & NUIlBER. APT. NO. <br /> <br />aTYlRlIIIIN <br /> <br />S1lTE <br /> <br />1J' COOlE <br /> <br /> <br />.~ <br /> <br />Iii <br />:1 <br /> <br />24.. l/IlTE SIGNED (110.. DIy, Yr.) <br /> <br />MI_ TIllE OF DEATH <br /> <br />I'r' <br />tdi <br />~I! <br /> <br />m <br /> <br />:Mc.PRONOUHCEOllEAO (110.. Ooy. Y'.) * TlEPIIONllIICEIlllEAD <br />m <br /> <br />:Me. On" _ '" __Ion -............11I"'1 .........."_11 <br />III.... .lIlIlCIpIICt IIlCIM lO III ClIUII(I)"'1ed. ...,.... and TIM). <br /> <br />2tb. WAS CONSENT GIWfTED" <br />NOI At/plU"" .1211 "NO CJ YES Q NO <br /> <br />2IL REGlSTlWI'S_lURE <br /> <br />.. DATE FILED BY REGlSfRAII (110.. DIr. ".1 <br />JAN 2 4 2007 <br /> <br />I <br /> <br />p <br /> <br />This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County <br />Health Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions <br />of this green certificate are not legal copies. <br /> <br />Date Issued: <br /> <br />'JAN 24 2DW <br /> <br />Registrar: <br /> <br />.it' cflS- ::> ~ <br />e. ~__ .... <br />I:" . .. . -::f-- 0 t...;,r <br />