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V W Z a z F:,1 _1 C H t/1 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH . .� SERVICES +` SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGWAL- __ WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST _ is THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE = u R} 3/4/2004 200, 500381 �L NQISMAR ?:r p. y' d,ASISTAN1iM'�R LINCOLN, NEBRASKA HEALTH ANkiF A�I� , STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND I�yA9SFA -1V i 'ANDSUPPORT VITAL STATISTICS - I°t I'`ti i.r. n TTT^Tn A TC nII Ili. A TL7' _ _ _ .. {] `,J 1. DECEDENT -NAME 3 D27 r( Ray Clifford Wibbels Male - February 2004 4. CITY AND STATE OF BIRTH (Il not in U.S.A.. name country/ 58. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAV 6. DATE OF BIRTH /Marts. Day. Year) �J Sc. HOURS ' MINS. October 13, 1925 o tit 7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATHj�� OTHER_: ❑ Nursing Home � rr� n (1 �•••. o -+ N c,J rD Hastings, Nebraska Yas No ❑ Adains c m u Grand Island 4319 Michigan Ave Yee KT No s� r.� m 13 NAME OF SPOUSE fit wile, give maiden name) etc.)lSpecify) White H Danish NEVER DIVORCED MARRI Veda McCain 14a. USUAL OCCUPATION /Give kind of work done during most C 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary 10 -121 College 11 -4 or 5 -1 dl working even dredred) Retired Farmer Own Farm SURNAME 16. FATHER -NAME FIRST MIDDLE ? o ° o �- 19a. INFORMANT - NAME (Yes, no. or unk.) (If yes. give war and dates of serviced Veda W i b b e 1 s WWII 1944 -1945 Yes 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP`t)++ 4319 Michigan Ave o METHOD DATE EMETERY OR CREMATORY NAME LM - SIGNATUR LICENS �200�4HU /j I [/ �Bunal ❑Removal Mar 2 lside Ce metery V 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE ❑ Cremation ❑ Donation Nebraska 22b. FUNERAL HOME DRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 411 " O„ street St. Pau 1 NE 68873 y Interval between onset and death (ENTER ONLY ONE CAUSE PER LINE FOR 1al. (bl. AND (c)) PART I 1 (ai I r- L 1 r gfih6nj DUE T A CONSEQUE A (T I I Interval between onset and death n (c) G OTHER SIGNIFICANT C DITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A ' 24 AUTOPSY 25. EXAMINER OR CORONER MEDICAL PREGNANCY IN THE PAST 3 MONTHS PART 11 (Ages 10 -541 Yes No Yes No Yes No 26a. b. DA1rE OF INJ ( .. Day. rt 26c. HOUR OF INJURY 268. DESCRIBE HOW INJURY OCCURRED h - M Suicide [] Pending 26e. INJURY AT WORK 261. office building U -(to . farm. street. factory �A E qq BB 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ No - 28a. DATE SIGNED (MO.. Day. Yr) 28b. TIME OF DEATH M z. l 27b, DATE SI ED .. Da 27a TIME OF DEATH i G } 28c. PRONOUNCED DEAD tMo.. Day, Yr) 28d. PRONOUNCED DEAD (Hour) J f r W i M /YcJ /� V $ 27d. To the best my kno edge. dea occur / M g z date a place and d to Ma o 26e. On the basis of examination and or investigation, in my opinion death occurred at v a the time, date and place and due to the causes) stated. causelst stated. ' r (Si nature and TNe) 29. DID TOBACCO CONTRIBUTE TO T E DEATH? (Si nature and Titie 30.a HAS ORGAN OR TISSUE DO TIOoN BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES �0 YES ❑ NO ❑ UNKNOWN !� rt cn ra W °�3 d co CI) p._.A CD cn 7.. C6 V W Z a z F:,1 _1 C H t/1 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH . .� SERVICES +` SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGWAL- __ WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST _ is THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE = u R} 3/4/2004 200, 500381 �L NQISMAR ?:r p. y' d,ASISTAN1iM'�R LINCOLN, NEBRASKA HEALTH ANkiF A�I� , STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND I�yA9SFA -1V i 'ANDSUPPORT VITAL STATISTICS - I°t I'`ti i.r. n TTT^Tn A TC nII Ili. A TL7' _ _ _ .. {] `,J 1. DECEDENT -NAME 3 D27 r( Ray Clifford Wibbels Male - February 2004 4. CITY AND STATE OF BIRTH (Il not in U.S.A.. name country/ 58. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAV 6. DATE OF BIRTH /Marts. Day. Year) (Yrs.) 78 Sb. MOS. DAYS Sc. HOURS ' MINS. October 13, 1925 Wolbach, Nebraska 7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATHj�� OTHER_: ❑ Nursing Home 508-28-94-39 HOSPITAL ` Inpatient ❑ ER Outpatient Residence ❑ �A ❑ Other (Spector 8b. FACILITY - Name llnot instXu6on, give street and number) Mary Lanning Hospital 8c. CITY, TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Hastings, Nebraska Yas No ❑ Adains 9a RESIDENCE - STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Cade) 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 4319 Michigan Ave Yee KT No 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (a.q.. Italian. Mexican. German, et I - 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE fit wile, give maiden name) etc.)lSpecify) White (Spy' "' Danish NEVER DIVORCED MARRI Veda McCain 14a. USUAL OCCUPATION /Give kind of work done during most C 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary 10 -121 College 11 -4 or 5 -1 dl working even dredred) Retired Farmer Own Farm SURNAME 16. FATHER -NAME FIRST MIDDLE (AST 17 MOTHER FIRST MIDDLE MAIDEN Algie Wibbels Lollie A. Anderson 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yes, no. or unk.) (If yes. give war and dates of serviced Veda W i b b e 1 s WWII 1944 -1945 Yes 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP`t)++ 4319 Michigan Ave aIndIT10N NE 68803 Grandy Island, METHOD DATE EMETERY OR CREMATORY NAME LM - SIGNATUR LICENS �200�4HU /j I [/ �Bunal ❑Removal Mar 2 lside Ce metery V 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE a. ERALHO E Jacobsen- ❑ Cremation ❑ Donation Nebraska 22b. FUNERAL HOME DRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 411 " O„ street St. Pau 1 NE 68873 23. IMMEDIATE CAUSE Interval between onset and death (ENTER ONLY ONE CAUSE PER LINE FOR 1al. (bl. AND (c)) PART I 1 (ai I r- L I Interval between onset and death gfih6nj DUE T A CONSEQUE I I I Interval between onset and death DUE TO, OR AS A CONSEOUENCE OF' (c) G OTHER SIGNIFICANT C DITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A ' 24 AUTOPSY 25. EXAMINER OR CORONER MEDICAL PREGNANCY IN THE PAST 3 MONTHS PART 11 (Ages 10 -541 Yes No Yes No Yes No 26a. b. DA1rE OF INJ ( .. Day. rt 26c. HOUR OF INJURY 268. DESCRIBE HOW INJURY OCCURRED Accident F� Undetermined M Suicide [] Pending 26e. INJURY AT WORK 261. office building U -(to . farm. street. factory �A E qq BB 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ No 27a. DATEOOF D TTH7 (M91. Day. Yr) 28a. DATE SIGNED (MO.. Day. Yr) 28b. TIME OF DEATH M z. l 27b, DATE SI ED .. Da 27a TIME OF DEATH i G } 28c. PRONOUNCED DEAD tMo.. Day, Yr) 28d. PRONOUNCED DEAD (Hour) J f r W i M /YcJ /� V $ 27d. To the best my kno edge. dea occur / M g z date a place and d to Ma o 26e. On the basis of examination and or investigation, in my opinion death occurred at v a the time, date and place and due to the causes) stated. causelst stated. ' r (Si nature and TNe) 29. DID TOBACCO CONTRIBUTE TO T E DEATH? (Si nature and Titie 30.a HAS ORGAN OR TISSUE DO TIOoN BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES �0 YES ❑ NO ❑ UNKNOWN ES ❑ NO Paul C. Wibbels MD 2115 N. Kansas Ave Hastings, NE 68901 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR /MO.. Day. W.) �t�►1i.t h MAR - 2 2004