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<br />\
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HU.J.M~ SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF, THE ORIGINAh-!!EC(jfiJtt;Hi-li!AE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAnPrC$Si!C71ON;,'@llf;H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . . iff~o7;=:.;.o'=:f./J~~ -'i,:
<br />
<br />~~~=~~ ~~
<br />JUN 1 3 2006 ASsiS1Aiii'stij-iliGGmRAR
<br />LINCOLN, NEBRASKA 2007069 319 HEii'iJH_:~~f!UoA~AN sERV/~ES
<br />
<br />~ '.. ~
<br />STATE OF NEBRASKA - D.E. .PAR...T.M. ENT OF HEALTH AND HUMAN S.. ERV. ICES FINANGE"Aili6:stiPP.-Ol}lj, 6 2. F 4' ",' 2' '. g. .:
<br />_ . GERTIFICATE OF DE~IH _~ . U u
<br />
<br />
<br />(First,
<br />Orville
<br />
<br />Middle,
<br />Keith
<br />
<br />Last,
<br />Reeves
<br />
<br />Suffix)
<br />
<br />2, SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr,)
<br />~ay 30, 2006
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5e. AGE-Last Birthday 5b, UNDER 1 YEAR
<br />(Yrs,) MOS. DAYS
<br />68
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />Overton, Nebraska
<br />
<br />August 10, 1937
<br />
<br />9520 S. Schauppsville Rd.
<br />
<br />-lea, PLACE OF DEATH
<br />
<br />
<br />-I tlQlifllli:
<br />L_.~
<br />
<br />U ER/Oul~alient
<br />
<br />XI .,?~_,!d8nl's_liome
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-42-3396
<br />
<br />U Inpallent
<br />
<br />OTHER:
<br />
<br />o Nursing Home/LTC 0 Hospice Facility
<br />
<br />FACILlTY.NAME (II nol institullon, give street and number)
<br />
<br />Home:
<br />
<br />o [0\ DOther(Speclfy)_..
<br />
<br />. ----~ ed COUNTY OF DEATH
<br />Hall
<br />
<br />ec CITY~~O;~ River
<br />- - _ 1ge AP:. NO tl~~~~3 -
<br />
<br />tOb. NAME OF SPOUSE (Flrsl, Middle, L.st, Sullix) It wite, give maiden name.
<br />
<br />ec. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Wood River
<br />
<br />9a. RESIDENCE.STATE
<br />
<br />Nebraska
<br />
<br />68883
<br />J~9bCOUNlY Hall
<br />
<br />9d. STREET AND NUMBER
<br />9520 S. Schauppsville Rd.
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />DYES :lfJ NO
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH 00 Married U Never Married
<br />
<br />o Divorced 0 Unknown
<br />
<br />Wilma Hansen
<br />
<br />Sullix) '-]12. MOTHER'S.NAME (First,
<br />Hattie
<br />. ---',--' .,,---..-- "_.._,~"--,-
<br />
<br />Middle,
<br />
<br />L.st,
<br />Reeves
<br />
<br />Middle,
<br />
<br />M.idan Surname)
<br />I.---.Hansen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />13, EVER IN U,S. ARMED FORCES? Give dete. 01 service If yes. 14a.INFORMANT-NAME
<br />(Yes,no,orunk.) No Wilma Reeves
<br />
<br />15'~::r~a~OFDI~~:~::i~~ 16a~~ /J / /
<br />
<br />o Cremalion 0 Enrombment 1~;;:- CEMETERY, CREMATORY O~~;ION ........---. .--..
<br />
<br />
<br />16c. DATE (Mo" Day, Yr. )
<br />June 3, 2006
<br />
<br />STATE
<br />
<br />CITY / TOWN
<br />
<br />o Removal 0 Olher (Specify)
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />Grand Island, Nebraska
<br />
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, City or Town, State)
<br />Apfel Funeral Home 1123 West Second,
<br />
<br />17b. Zip Code
<br />68801
<br />
<br />PART I. Enler the ~,e_Y.e,0lS.--dI5ea.se.s1 injurles, or complications..thal directly caused the dealh. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arresl, or ventricular fibrillalion wilhoul showing Ihe etiology. DO NOT ABBREVIATE. Enter only one cause on ellne. Add addlllonalllnes If necassary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />I
<br />I
<br />
<br />I onset to dealh
<br />I
<br />
<br />. ~irnrnediate
<br />
<br />I onsetto death
<br />I
<br />
<br />: 30 years
<br />
<br />I onsal to death
<br />I
<br />I
<br />I
<br />
<br />IMM~DtA T~ CAUSE (Final
<br />disease or condition resulting
<br />in death).
<br />
<br />(a)
<br />
<br />Heart Attack
<br />
<br />DUE TO, OR AS A CONSEQUENC~ OF:
<br />
<br />Sequentially list condltlons,lf
<br />any, leading to the cause listed
<br />on IIn8 a.
<br />Ente, the UNDERLYING CAUSE
<br />(di....e 0' Injury that Inltleted
<br />Ihe evenls ,esulllng In dealh)
<br />IA'n
<br />
<br />(b) Diabetes
<br />
<br />(insulin dependent)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />DUE TO, OR AS A CONSeQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />16. PART II. OTHER SIGNIFICANT CONDITIONS.Condition. contribuling to the death but nol resulllng In the underlying cause given In PART L
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />complained of flu-like symptoms to spouse within 24 hours of death.
<br />
<br />il YES
<br />
<br />U NO
<br />
<br />21a. MANNI::R OF DEATH
<br />il NaMal 0 Homicide
<br />
<br />2tb.IF TRANSPORTATION INJURY 210. WAS AN AUTOPSY PERFORMED?
<br />U Driver/Operator
<br />
<br />o Nol pregnant within pes I year
<br />o Pregnant at lime of death
<br />o Not p,egnanl, but p'.gnanl witl1ln 42 dsy. of dealh
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />o Unknown it pregnanl within the past year
<br />
<br />U YES l!I NO
<br />
<br />o Passenger
<br />o Pedestrian
<br />U Other (Speclly)
<br />
<br />o AccldenlD Pending Inve,tigation
<br />o Suicide 0 Could not be determined
<br />
<br />21d. WeRE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DeATH?
<br />DYES 0 NO
<br />
<br />22d, INJURY AT WORK?
<br />
<br />
<br />22a, DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY, 22c. PLACE OF IIJJURY.At "0",0, !arm, streel, faClory, "lIie. building, cc,ostruction site, elc. (Specify)
<br />
<br />. _.:..-1 ...._.__._u
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO,
<br />
<br />CITYrrOWN
<br />
<br />STfifE
<br />
<br />ZIP CODe
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />24a, DATE SIGNED (Mo., Day, Yr.1
<br />6-6-06
<br />
<br />24b. TIME OF DEATH
<br />4:00
<br />
<br />>-:;: ~
<br />.co2
<br />lliiii5
<br />jH
<br />Q. CL iI:( ::;
<br />E">-Z
<br />8ffi!i<0
<br />o>z=>
<br />-"00
<br />~a:O
<br />o ~
<br />00
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />5:10 am
<br />
<br />an (appr X.)
<br />
<br />23b. UATE SIGNED (Mo., Day, Yr.)
<br />
<br />23c, TIME OF DEATH
<br />
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />5-30-06
<br />
<br />m
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />
<br />23d. To the best of my knowladga, death occurred allhe timel date and place
<br />and due 10 Ihe cau.e(s) Slated. (Signature and Title) '"
<br />
<br />DYES I&l NO U PROBABLY 0 UNKNOWN 0 YES m NO
<br />V,'NAME, rillE ANDAOO-RESS OF CFRTIFj'ER (PHYSICIAN, CORON'ER'S PHYSICIAN OR 'COUNTY ATTORNEY) (Type or Print)
<br />
<br />231 S. Locust
<br />
<br />Not Applicable If 26a Is NO 0 YES 0 NO
<br />
<br />Grand Island NE
<br />2eb. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />JUN 9 2006
<br />
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