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<br />>
<br />
<br /> . ....E OF
<br /> 1. DECEDENT'S-NAME !F,..t, Mlddl., L..l sumo' lL SEX 3. DATE OF DEATH (Mo..D.y.V",
<br /> Clark Willis Reese Male June 22, 2008
<br /> 4. CITY AND STATE OR TERRITORV, OR FOREIGN COUNTRY OF BIRTH Sa. AGE.Lost Birthday 5b. UNDER 1 VEAR 50. UNDER 1 DAV 8. DATE OF BIRTH (Mo., Day, Vr.)
<br /> (V...) MOS. I DAVS HOURS I MINS.
<br /> Omaha, Nebraska 57 November 14, 1950
<br /> 7. SOCIAL SECURITY NUMSER Sa. PLACE OF DEATH
<br /> 0: 506-70-8316 /:IQl!f!!AI.: 00 Inpall...t 2II:!IiBi 0 N.....lng HomeIL TC o Ho.ploa F.olllty
<br /> ~ eb. FACILlTY.NAMI! (If not Inslllllllon, gl.... .tr..t and numb.r' o I;RlOutpaU.nt o D..,ad~nr. Homo
<br /> ~ Nebraska Medical Center-University ODOA o OlhortSpaclfy)
<br /> 2i
<br /> ...J 80. CITY OR ToWN Of DEATH (Inoludo Zip Cods) led. COU~TY Of DEATH
<br /> ffi Omaha 68198 Douglas
<br /> z Os. RI;SIDI:NCI:..sTATE 19b. COUNTY ISc, CITY OR TOWN
<br /> ::J
<br /> ....
<br /> j Nebraska Hall Grand Island
<br /> " Od. STREET AND NUMBER Is.' APT. NO. IOf. ZIP CODE log. INSIDI: CITY LIMITS
<br /> CD 68803 I!I v.. 0 No
<br /> -= 2123 W. Koenig
<br /> I 10.. MARITAL STATUS AT TIME OF DEATH iii M.rri.d o N.vor Marriadi:-~AME OF SPOUSE (FlraL Mlddl.. Lall sumo) If wife. glvo _Idon namo.
<br /> o Marriad, but s_rated 0 Wldowod o Dlvorcad DUnkno:,"_ __ en WaId- __ __ ___ ___.-
<br /> A. 11. FATHER'S-NAME (Firat. Mlddl.. L.... sumo' 1'2. MOTHI:R'S-NAME (Flral M.ld.n Sum.me)
<br /> E Middle,
<br /> 8 Walter Willis Reese Irma Jahrmarkt
<br /> .z 13. EVI:R IN U.s. ARMED FORCES7 Glv. dat.a ofoarvlc. If V... I. ;~::RMANT-NAMI: 14b. RELATIONSHIP TO DI;CI:DENT
<br /> {!. are~ Wife
<br /> (Vo.. No, or Unk., No eese
<br /> 15. METHOO OF DISPOSITION 18.. EMBALMER-SIGNATURE I leb. LICENSE NO. lec. DATE (Mo., Day. Vr.1
<br /> oB"".1 DDoQfltlon Not Embalmed June 24 200R
<br /> IiiI Cram....n De:ntomtlmlnl STATE
<br /> ollem...1 DOlh.rISp.ollyl led. CEMI:TI:RV, CRI:MATORV OR OTHER LOCATION CITYITOWN
<br /> Autumn Hills Cremallon Services Omaha Nebraska
<br /> 170. FUNI;RAl HOME NAME AND MAILING ADDRESS (Street. City or Town, Stete) 17b. lip Code
<br /> Mid America First Call, Inc., 4425 S. 24th Street, Omaha, Nebraska for 68107
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH (See Instructions and examples)
<br /> U. PART I. Enter the cIuIIrt of ..,.,.,. . d'.8IM., InJur1t1., OJ' complkatfon... UuM: dlrwctlt I:$lnd the d_lIIUI_ DO NOT .r1ler .""'nll eQm luch II ctrdfac Imll, I APPROXI"'ATI;
<br /> INTERVAL
<br /> ...lIIlitratnry .,..at, or vttnttti=.I,II... flbtJH.tI~n wtthout Ihowlrla 8M etlolOlllY. DO NOT ABBREVIATE. Enttr onl, OM CIUH on .Itn.. Add Iddttionll a... If I1HeUlry. I
<br /> IMMr;iDlATI: CAUSI;: , On..' to d..th
<br /> IMlIIIl:otA TI; CAUSI; (Final ,
<br /> r IwttLK
<br /> dlse.B' or condlUon ....sultlng e) S~'S I
<br /> In "".th' ,
<br /> ,
<br /> DUE TO, OR A CONSEQUENCr;i OF: i Dnset to death
<br /> I
<br /> SequentlBlly list conditions, If b) 'POll ~{o pt.t\ ,0.. I 2.. l'YU1'\.th3
<br /> I
<br /> eny, l.lIdlng to Ihe c..... listed I
<br /> online.. ,
<br /> DUI: TO. OR AS A CONSEQUENCE! OF: I onset to dII.th
<br /> A co.b- tl1Hdo ,'0. Lwll. e.h1l 0- , .3 tl1D t\.f:hs
<br /> ,
<br /> Enter lI1e UNDERL VING Cl\USI: 0' r
<br /> (dl..... or In)ury th.t Inltl.t.d ,
<br /> thellvent. resulting In death) DUE TO, OR AS A CONSEd'UENCE OF: I on.et to de.th
<br /> LAST I
<br /> I
<br /> -,
<br /> d) r
<br /> le. PART II. OTHER SIGNIFICANT CONDITIONS-Condlllone contribullng to the daalh b"t not raeulllng In lI1e underlylngoau.. glv.n In PART I. lS. WAS MI:DICAL EXAMINI:R
<br /> OR CORONER CONTACTED?
<br /> n:: o YES .yt NO
<br /> W 20. IF FEMALE: 210. MANNI;R OF DEATH 21b.IF TRANSPORTATION INJURV 2ic. WAS AN AUTOPSV PERFORMED7
<br /> IT: o Nat pregnant within p.st y,.r g, N.t"",1 )(tNO
<br /> ~ o Homl.lde D Drlv.,.,Op.rator OVES
<br /> W o P"'gn.nl .t limo .f doath o A.old.nl 0 P.ndlng In.....lIg.lI..n o P....ng.r 21d. WERE AUTOPSV FINDlNG8 AVAILABLE
<br /> 0 D Not pragnant, but progn...t within 42 days of daalh o Sul.lde o Could not b. determined
<br /> j o P.d"trlen TO COMPlI:TE CAUSE OF OI:ATH?
<br /> o Not p..gnant. but pragnllnt 43 deJ. to 1 year b.fore death o OlI1or ,SpoclfyJ OVI:S !(Ho
<br /> ! OUnknown If progn.nt wllhln Ih. Palt y.ar
<br /> '6. I 22b. TIME Of INJURV 122.. PLACE OF INJURV-At horn., ferm, strael fa.tory, om.e building, .onelnlodon elte, eto. (Spe.lfy)
<br /> -8 22e. DATI; OF INJURV (Mo., Dey, Vr.)
<br /> q
<br /> .z 22d.INJURV AT WORK? 122.. DE8CRIBE HOW INJURV OCCURRI:D
<br /> ~ DVES DNO
<br /> ;. .~." 22f. LOCATION OF INJURV. 8TRI!ET 8. NUMBER, APT. NO. CITYI'I'OWN STAT!! ZIP CODE
<br /> , .. >'
<br /> -, I~ >
<br /> : 23a. DATE OF DEATH (Mo., Day, Vr.) ~~~ 240. DATE SIGNED ''''0., Day, Vr.) 24b. TIME OF DEATH
<br /> ~~ l' W\.L 2.2.. 2.001 m
<br /> U
<br /> l~~ 23b. DATE SIGNED (Mo., Day, Vr.) 1230. TIMI: OF DEATH I~ >- 24<:. PRONOUNCED DEAD (Mo., Dey, Vr.) 24d. TIME PRONOUNCED DEAD
<br /> r-z 'J" tAIUZ. 2.! I '2..6011 12.: 01 'P m E~..c :Ii! m
<br /> 2'0 23d. To Ih. be.t of my knowl.dg., d.oth ocourrod et Iho Ume. d.t. and pla.o 8;~ 0
<br /> :1 2... On the ._Ie of e..mlnaUon andlor fnv..Ug.Uon, In my opinion d.ath occurred
<br /> and duo to lI1a .auaola) .toted. (Slgnatura end Till.' .8 0;:) ot lI1a II""" dete _ place and duo to Ih. ca....,aJ.tot.d. (8lgnatunt end TIlle'
<br /> &;({H1. M~l~~)}-~-- ~m::8
<br /> 1------ 0.... -~.....'.
<br />-r"" ....-~ Uo .. ."~
<br /> 25. DID TOBACCO U81! CONml"'UTE TO. TH~:'t"'1' c: ~~2e", HAS ORGAN OR TISS)a.DONATION BEEN CONSIDr;iRED7 l2Ib. WAS CONSI:NT GRANTED7
<br /> o YES 0 NO D PRoeAE,lLv .f N~%;..' rr I}'YES NO Not Applloa"'e I\' 210 Ie NO 0 YES DNO
<br /> 21. NAME, TITLE AND ADDRESS !?FCERTlI<IE"~SICIAN, COR~8~J,CrAtl OR COUNTY AT'rQltNEv) (Typa or Prlntl
<br /> ',I ...,.,. . ",. I
<br /> Dr. L..r ...... Mn4aTli:1. 8t1Jee.t and Emile Street Omaha Ne 6R19S
<br /> p 280. REGISTRAR'S SIGNATUPl ~.G'..."'- ~\.-~ leb. DATE JLUNV iEOrioU8' Oey, Vr.,
<br /> ~ (". '- .::/;.,. .C!J t::.AAr.
<br /> . ,-- .6. '.
<br /> >-~ ,. .- .
<br /> .
<br />
<br />2 0 0 90 312 7 STATE OF NEBRASKA" DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />
<br />331349
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<br />.1 ",' ,...-- llIlll1/o """ .~. '"t4'IJ
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<br />'1' .r (, ,4, ..) ./fI" ,'.
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<br />...l- ['\. '-- C' (\,.j
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<br />This certifies this dOCtllnert~tobe a true copy of an original record on file with Vital Statistics, Douglas CO~lI1ty
<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 />~ c.7egistrar:
<br />
<br />Date Issued:A~
<br />
<br />JUN.232OO8
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