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<br />STATE OF NEBRASKA
<br />
<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 RECORD ON FILE WITW
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHIC/! IS
<br />
<br />::::::::S:,:;TORY FOR YfTAL RECOROSIV~,:-<,i:.~,p
<br />JAN 0 8 2008 P"""''':;JtTMM-f,''S:~ER
<br />. .. 20080054 5 ASSIEtIWf,.......\~T1.fF...RtGis:rtQ~R\
<br />LINCOLN, NEBRASKA H~A~~~FM~f SjR(! '.
<br />
<br />/ ~'.,. . ~~ .. '\ T ;i' .~'t:. ~.J' .
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<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE~,F~A~~~~~SMP~ ... :';
<br />CERTIFICATE OF DEATH .' ;':.,.... .:.
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<br />-. .~:
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<br />1. DECEDENT'S-NAME (FirSI,
<br />Lester
<br />
<br />Middle,
<br />Eugene
<br />
<br />Last,
<br />Wells
<br />
<br />Sulfix)
<br />
<br />SE~
<br />Male
<br />
<br />,.
<br />':'~"..
<br />
<br />.aan
<br />
<br />Horace, Nebraska
<br />
<br />Sa. AGE-Last Birthday
<br />(Yrs.) 74
<br />
<br />
<br />50. UNDER 1 DAY
<br />MINS.
<br />
<br />S.'DAT. OF DEATH (Mo., Day, Yr.)
<br />December 20, 2007
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<br />6. DATE OF BIRTH (Mo., Day, Yr.)
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<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />November 23, 1933
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-32-8085
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<br />6a. PLACE OF DEATH
<br />l:l.Q.Qf.lTAL; 0 Inpalionl
<br />
<br />QlliE8; 0 Nursing Homo/LTC 0 Hosp'co Facilily
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<br />FACILITY-NAME (If not inslilution, give str.ol and numbor)
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<br />Home:
<br />
<br />1219 West 9th
<br />
<br />o ER/Outpaflent
<br />
<br />m Decedent's Home
<br />
<br />(0)\
<br />
<br />o Olhor (Specily)
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<br />6c. CITY OR TOWN OF DEATH (Includo Zip Codo)
<br />
<br />Grand Island
<br />
<br />68801
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<br />6d. COUNTY OF DEATH
<br />Hall
<br />
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />Xl YES 0 NO
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<br />9a. RESIDENCE.STATE
<br />Nebraska
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<br />9b. COUNTY
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<br />9d. STREET AND NUMBER
<br />1219 West 9th
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<br />lOa. MARITAL STATUS ATTIME OF DEATH OIMarried 0 Never Married lOb. NAME OF SPOUSE (Firsl, Mlddla, Last, Suffix) II wile, give maiden name.
<br />
<br />o Marriod, bul separaled Q Widowed 0 Divorced 0 UnKnown Doris Hagen
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<br />11. FATHER'S-NAME (FirSI,
<br />Melvin
<br />
<br />Middle,
<br />J.
<br />
<br />LaSl,
<br />Wells
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Fern
<br />
<br />Middle,
<br />H.
<br />
<br />Maiden Surname)
<br />Johnson
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of service il yes. 14a.INFORMANT.NAME
<br />No Doris Wells
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<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16b. LICENSE NO.
<br />13~5
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<br />16c. DATE (Mo" Day, Yr. )
<br />December 22, 2007
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<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />Grand
<br />
<br />respirafory arresl, or ventricular fibriilation withoul showing Ihe ellology. DO NOT ABBREVIATE. Enler only one ceuse on a line. Add addllional line, If necessary.
<br />
<br />IMMEDIATE CAUSE (Flnal
<br />disuse or cond~lon re",,~lng
<br />In dseIh)
<br />
<br />
<br />onset to dealh
<br />
<br />(a)
<br />
<br />_~J:~;J "l_____
<br />
<br />onset to death
<br />
<br />Sequentially list conditions, if
<br />eny, Ieedlng to the ceueelleted
<br />onlln&ll.
<br />~Ier the UNDERLYING CAUSE
<br />(dl..... or Injury thallnltl.lod
<br />the events rnu~lng In dnlh)
<br />LAS!'
<br />
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on'ello dealh
<br />
<br />(d)
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<br />16. PART II. OTHER SIGNIFICANT CONDITIONS.Condilions contributing to the death but not resulting in the underlying cause given in PART I.
<br />
<br />21 a. MANNER OF DEATH
<br />~ral 0 Homicide
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<br />Q AccidentQ Pending Investigation
<br />
<br />o Suicide 0 Cculd not be delermined
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<br />21 b.IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
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<br />Q Pedestrian
<br />
<br />Cl Olher (Specily)
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<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />Q YES :KJ NO
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />
<br />",~~~'4\.~../':A9
<br />20. IF FEMALE:
<br />o Not pregna.nt within past year
<br />Q Pregnant at time of death
<br />o Not pregnant, but pregnant within 42 days of dealh
<br />o NOI pregnanl, but pregnent 43 days 10 1 year before death
<br />Q UnKnown If pregnanl within the past year
<br />
<br />.J...:: ~
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<br />U YES ~
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<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES ~
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<br />22a. DATE OF INJURY (Mo., Day, Yr.)
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<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, farm, slreel, faclory, office building, conslruclion sile, etc. (Specify)
<br />
<br />m
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<br />22d.INJURY AT WORK?
<br />o YES ~
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<br />1220. DESCRIBE HOW INJURY OCCURR.D
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<br />221. LOCATION OF INJURY - STREE:r & NUMBER, APT. NO.
<br />
<br />CITYfTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
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<br />23a. DATE OF pEATH 1M... QlIy. YWOO?
<br />Decemoer ..:U,Z
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<br />. 24e. DATE SIGNED (Mo., Day, Yr.)
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<br />24b. TIME OF DEATH
<br />
<br />~~~
<br />_II:
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<br />io..ic:C~
<br />..~z
<br />"'%0
<br />1l!:l!:.
<br />~:f8
<br />815
<br />
<br />m
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<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
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<br />246. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, dale and place and due to Ihe cause(s) stated. (Signeture and Title)"
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<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CDNSENT GRANTED?
<br />
<br />.._.__9~~~__...~ 0 PRO_BABLY a UNKNOWN 0 YES _ ~ Not Applicable if 26a is NO Q YES'~
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY)IType or Print)
<br />Ryan Crouch D.O. 800 Alpha Ave.. Grand Island, NE. 68803
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<br />28a. REGISTRAR'S SIGNATURE 26b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
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<br />DEe 2 8 Z007
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