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<br />STATE OF NEBRASKA
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<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OFHEAL TH AND HUMAN SER VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE iVEBRASr4.-fiJ.~7Uj1'4{jf:VT OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR;'CIfi;~~ ~~~~'!!?:'~\ ii, . '.. ..... ,
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<br />DATEDFISSUANCE ~d:~
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<br />8 2 0 18 9 .5T<MLEYS. c;..OOPER... '.. '
<br />OEe 22 200. 009 0 ;AglSTANT"~TATEREGIS{RAW;
<br />'.;DEP~RTMerJ!f:O~f1EfoL TH ANb;;
<br />LINCOLN, NEBRASKA IH1J!1~N ~F!lft.C!Eg..'-...J ..:',
<br />Iv" .,-..
<br />Ep~ A . r
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<br />.~ STATE OF NEBRASKA - DEPARTMENT OF HEALTH ANDHUMANS ,.. ./..~~'sQ8c.'iS2'5-7:D
<br /> . a""E OF I lpoa I .,.
<br />1. DECEDENTS-NAME (FI..I, Mlddl.. Laal, Sufllx) 2. SEX (. v I' 3.I1KreO~ ~\It{eI~J2JY.Yr.)
<br />~ 't . '!)~Wki\ . ;,. . -..
<br />Bill Lee Whitaker Male t ..&l ~ ber~HJ,;:l008
<br /> ~ 4. CITY AND STATE OR TE;RRlTORY. OR FOREIGN COUNTRY OF BIRTH Sa. AGE-La.1 Blrt/lday &b. UNDER 1 YEAR &C. UNDER 1 DAY I. D;."rO" lIIRTH (Mo., Q,ey, Vr.)
<br /> MOS. I DAYS .'... .
<br /> (Y...) HOURS I MINS. ..~ "", -........
<br /> Pawhuska, Oklahoma 76 March 4. 1932
<br /> 7. SOCIAL SECURITY NUMBER I.. PLACE OF DEATH
<br /> 509-20-9941 ~ 0 Inpetl.nt lUJWl;. 0 Nu..lng Ho<n*IL TC o Hosplcs Fsclllty
<br /> Sb. FACILITY-NAME (II nolln.UlUllon,glve .""".nd nUmb.r) o ER/OuIplIUant iii o.cadenr. Home
<br />I, 2418 N. Custer OOOA o Othor(Spsclfy)
<br /> ..l .c. CITY OR TOWN OF DEATH (Includ. Zip Coda) lid. COUNTY OF DEATH
<br /> ~ Grand Island 68801 Hall
<br /> w
<br /> z 'a. RESlDENCE.STATE I 'b. COUNTY I 'c. CITY OR TOWN
<br /> OC
<br /> !- Nebraska Hall Grand Island
<br /> 'i ad. STREET AND NUMBER -'''' APT. NO. 111I. ZIP CODE I Sg. INSIDE CITY UMITS
<br /> i 2418 N. Custer 68801 I!I Vs. 0 No
<br /> i 10.. MARITAL STATUS AT TIME OF DEATH iii M.m... o Nsysr M.m... . 10b. NAME OF SPOUSE (FI..I, Mlddls, L..I, Sufllx) II wlls. give maiden nome.
<br /> o Msn1.... bul up.ll1ed 0 Wld"...d 0 Dtvorc'" o Unknown Donna Caldwell
<br /> Cl. 11. FATHER'S.NAME (FI"1, Mlddl., Sulllx) 112. MOTHER'S-NAME (FI..I, Mlddl.. M.ld.n SUrname)
<br /> E Lul,
<br /> 0 Geraldine Menkhoff
<br /> u Rov Whitaker
<br /> dl 13. EVER IN U.S. ARMED FORCES? Glya d.IU 01 a.IVlcs "Ya.'11... INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> ~ (n.. No, or Un~.) No Donna Whitaker Wife
<br /> 11. METHOD OF DtSPOSlTION 11a. EMBALMER-8IGNATURI! I 11b. LICENSE NO. 16c. DATE (Mo.. D.y, Yr.)
<br /> o Burtol O""..uon Not Embalmed December 15, 2008
<br /> IiiIc_,on DEntoInbmonl 1.d. CEMETE;RY. CREIIIATORY OR OTHER LOCAnON CITYITOWN STATE
<br /> O-oJ Oothor(lpocIIyl
<br /> CBntral Nebraska Cremation Service Gibbon Nebraska
<br /> 17a. FUNERAL HOME NIIME AND MAlUNG ADDRESS (SInIeI, City or Town. S_) 17b. Zip Cod.
<br /> All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH (See instructions and examples)
<br /> 11. PART I. Entw the chin alMIMU . d......, InJUI'tt., or ~__ tMt cUredty cauNCt... ........ DO MOT...................... ...en as ctInIR ......... I APPROXIMATE INTERVAL
<br /> ....plr..ory amt.t, 01' .,.nlncdlar ftbrlll.don without snowing th. .t1olouy. DO Nol AaBREVlATE.. e...... only on. CIUM em . 11M. Add additlonlllln... H "~.."ry. I
<br /> IMMEDIATE CAUSE: ' on..t to d..U.
<br /> I
<br /> IIIIMEDIATE CAUSE (Final I
<br /> dl..... or condlllon ...uIUng .) .pll~ I V1.-(-e.JC s
<br /> In d.all1) I
<br /> DUE TO, OR AS A CONSEQUENCE OF: : ons" to d.ath
<br /> I I ~_
<br /> SequenU.lly 11.1 conditions. II b) S~ Cl> pO I
<br /> .ny.l.adlng 10 th. c.u..llaled ~ -,.,- .
<br /> on IIn. a. DUE TO, OR AS A CONSEQUENCE OF: : on..t to d..th
<br /> I
<br /> ;"lrs~ ".{- -h~ ~< I
<br /> Enl...... UNDERLYING CAUSE! c) : ""~:
<br /> (dl..... or Injury lI1atlnlll.l.d DUE TO, OR AS A CONSEQUENCE OF: : on..t to d..th
<br /> 111. syenle ...ulllngln dsslh)
<br /> LAST I
<br /> I
<br /> I
<br /> d) I
<br /> 1&. PART II. OTHER SIGNIFICANT CONDmONS.condIUona conlrlbullng 10 111. dealh but nol re.ulUngln II1s underlying c.u.. given In PART I. 18. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> DYES II NO
<br /> 'ra::
<br /> W 20. IF FEMALE: 210. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ii: o Nol pregnanl wllI1ln put yosr ~.lUrel o Homicide o DrlverlOpsrelor DYES giI NO
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<br /> W o PIIgn8ll1 ..lime 01 d..1I1 o Accld.nl 0 P.ndlng Inv..Ugallon o P....ng.r 21<1. WERE AUTOPSY FINDINGS AVAILABLE
<br /> U o Nol pregnsnt, but pregnsnl within 42 d.ye 01 daath o Suicide o Could nol b. determlnod o ped.atrlan TO COMPLETE CAUSE OF DEATH?
<br /> !- o Nol pregn8ll1, but pregnanl43 deye 10 1 y... __ da.th o Oth.r (Speclfy) DYES ONO
<br /> ) o Un~nown " pregnenl within.... pul ye.,
<br /> Cl. .1 22b. TIME OF INJURY 122C~ PLAC~. ~F I~J~~-AI home.I.rm, allelll, laCIOry: omc. building, consbucUon .11., .tc. (Spsclly)
<br /> ~ 220. DATE OF INJURY (Mo.. D.y, Yr.)
<br /> U . -- . -
<br /> ill - ' .n
<br /> 0 22d. INJURY AT WORK? 22.. DESCRIBE HOW INJURY OCCURRED
<br /> .... DYES ONO
<br /> 221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
<br /> 2ao, DATI! OF DEATH (Mo., Pay, Yr.) ~~~ 24e. DATE SIGNED (Mo.. Dey, Yr,) 21b. TIME OF DEATH
<br /> ~~ December 13. 2008 m
<br /> f! !.!~
<br /> -~>- 23b. DATE SIGNED (Mo., Pay. Yr.) 1230. TIME OF DEATH J 11I0 24c. PRONOUNCED DEAD (11I0.. D.y. Yr.) 24d. nME PRONOUNCED DEAD
<br /> ~~ >-
<br /> O'D.... I J. '" /5- 0 P. 7.nn '" m o.D..c...l
<br /> E ",Z g 1Il~ ~ m
<br /> 8.!:0 23d. T"mn my ~nowladga, d..lh occurred alth. Ume. dele snd plsc. U~Z 24&. On Ihe b..la 01 ax&mln.Uon and/or Inyssllg.Uon. In my oplnlon de.1ll occurred
<br /> 1:1l end due r"J~.ue~ alalsd. (;.; end TIll.) 1: 0:;) elth. Ume, dole and plec. .nd dll. to th. causs\.)atel8d. (Slgnalure end TlU.)
<br /> .2~ OJ!O
<br /> ... ~
<br /> 1)0
<br /> 21~:OBACCo.UlE CONTRIBUTE TO THE DEATH? \280, HAS ORGAN OR TISSUE DONATION BEEN CONSlDERI!D? 121b. WAS CONSENT GRANTE;D?
<br /> ES 0 NO 0 PROBABLY 0 UNKNOWN o YES ~NO NOI Appllcabla 11280 I. NO 0 YES <<,NO
<br /> 27. HAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Prinl)
<br /> Jav Anderson M.D 729N ~- AVA - .. T", 1",,,, ~ . .k", 68803
<br /> 2Ba. REGISTRAR'S SIGNATURE M-.~ 1 (MhlA . 21b. DATI! FILED BY REGISTRAR (Mo.. Day, Yr.)
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<br /> DEe 1 8 2008
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