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STATE OF NEBRASKA
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<br />~. WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITM THE NEBRASKA'DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH TS THE LEGAL'DEPOSITORYEOR VITAL RECORDS.
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<br />DATE OF ISSUANCE ~•; '~~
<br />MAR $ 5 2009 ~srANLEY S, COOPER.
<br />2 0 0 9 o s 3 0 5 =,4SS15.tA~'- STAFF REGISTRAR
<br />DEPAk~I-~~'1U~",OF'HEAL°rh AND
<br />LINCOLN, NEBRASKA ";1+ILlMAN SERVICES., .~ ,
<br />STATL OF NEBRASKA - DE IF TMENT 01= HEALTH AND HUMAN Sf=RV.ICES ~? ~ .i~ ~ 2"~.5 3 4
<br />1, DECEDENT'S-NAME (Flrat, Middle, Last, Surflx) 2. SEX _ 1. ;pqT .Op E_gTN (Md.,Dry,Yr.)
<br />~_ Wilbur Daniel Nielsen Male `March 12, 2009
<br />4. CnY ANO BTATE OR TERRITORY, DR FOREKiN COUNTRY OF BIRTH 8a. AOE•Lut Birehdry 8b. UNDER 1 YEAR 6c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr,)
<br />IY~•1 MOS. DAYS HOURS MINE.
<br />Cotesfield, Nebraska
<br />7.8pCIAL SECURITY NUMBER
<br />8b. FACILITY-NAME (N not Irtetltudon, plus ureat and number)
<br />W
<br />Saint Francis Medical Center
<br />Bc. CITY OR TOWN OF DEATH (Include ZIp Cade)
<br />W Grand Island 88803
<br />j tM. RESIDENCE-STATE tlb. COUNTY
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<br />~, Nebraska ~ Hall
<br />ed. STREET AND NUMBER
<br />424E 16th Street
<br />1tle. MARITAL STATUS AT TIME OF DEATH ®Merrled ^ Navar Mai
<br />^ Merdad, but uparatsd © Widowed ^ glvorCed ^ Unknown
<br />12. MOTHER'S-NAME (flat, Middlr, Malden $um8me)
<br />Anna Mortensen
<br />18b. LICENSE NO.
<br />l.~D
<br />^R.moval ^Olnaryaprclry) 1tltl. CEMETERY, CREMATORY pR OTHER LOCATION
<br />CI7Yrn7WN
<br />Grand Island City Cemetery Grand I$land
<br />17a. FUNERAL HOME NAME AND MAILINp ADDRESS (Street, City or Town, $4te)
<br />Jacobsen-Greenway Funeral Home, 411 O Street, PO Box 112, St. Paul, Nebraska
<br />65
<br />t1r. PLACE OF DEATH
<br />li~llAL; ®mpeaem ,.
<br />^ ERK)utpatlrm
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<br />November 12, 1943
<br />OTNEBi ^ Nuning Home/LTC ^ Hospiw Faclllty
<br />^ Decedent's Hums
<br />^ Other(Bpacity)
<br />$d. COUNTY OF DEATH
<br />Hall
<br />8c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO. !K. 21P CODE 9g. INSIDE CITY LIMITS
<br />88801 ®Y~s ^ No
<br />ttlb. NAME OF SPOUSE (Finn Middlr, Leer, 8uRlx) tl wih, give m8tdrn n8me.
<br />Connie Lavher" '
<br />11. FATHER'S-NAME (Flrat, Middle, LBSL Surflx-
<br />Robert Nielsen
<br />1~. EVER IN U.S. ARMED FORCE$7 Give dates o/ eenriw Ir Yu. 14a. INFORMANT•NAAAE
<br />(Ya, No, Or Unk.) NO Connie Nielsen
<br />16. METHOD OF DISPOSITION a. EMBALMER-SIGN
<br />®BuMI ^bonetlun
<br />©riladLtlnn ^I:IdornemeM
<br />'- ry~naa~ er Compllmuoge-rMr dln
<br />n)aplndory rmat, or wnlrlcuMr RedNMlen vArlrout rhrMeq the atlnloeY. (X1 NoT
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />) ~ ( ~..
<br />ni d 81h ~ cdndlRon ruuNing a) ` i
<br />DUE TO, O $ q CONSEQUENCE OF:
<br />Sequsmially Ilet conditlone, tl b)
<br />any, leading to the cause Ilated
<br />on Iim 8. DUE TO, OR AB A CONSEOUENCE p
<br />Entw the UNDERLYING CAUSE c)
<br />(dlsaeae er In)ury met Inldated
<br />the events rewltlng in death) DUE TD, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />18. PART II.OTHER $I(iNIflCANT CONDITIONB.Conditlene
<br />ar y - .p ~.....
<br />_ ..... ..yt. 10.1F7rEMALE:
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<br />^ Not pnlgrNrm witldn pest year
<br />W ^ Pregnant 8t tlrlte M death
<br />V ^ Not
<br />prepnaM, but prepnent within 42 tlaye or deem
<br />^ Not pregnBnL but prognam 43 days to 1 year before
<br />~ Unknown H
<br />^ piegnant within tlta put year
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<br />22f. LOCATKN OF INJURY -STREET 6 NUMBER, APT. NO. CITYITOWN
<br />DEATH (See instructions and example
<br />wuaW dla death, 60 SNOT engr rmnlnal aviMi inch q u~ralu near, ~-.
<br />9REVIATe. Enbr only ens caws an a Ilm. Add eddNlanal anu 8 nacasaary.
<br />iMbutinp M thr dst~but nLgt
<br />w
<br />ltl^ng Ian the underlying cause given In PART 1.
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<br />21a. MjMNER OF DEATH
<br />/ 21b. IF TRANSPONTATION INJUF
<br />eluml ^ Homicide
<br />Lrtl,'N ^ DIIwnOFwstar
<br />^ AcaWem ^ PendinglmastlgaUon ^ Paasengar
<br />^ $Wcide ^ Could not ba determined ^ PWealdBn
<br /> ^ Other(BpacNy)
<br />22a. DATE OF INJURY (Mo., pry, Yr.) 22b.'TIME OF INJURY 220. PLACE QF INJURY-Ae home, rum, stmt, rectory, oN1w building, ooneWctlhn site, rte. ($peciryr)
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<br />d
<br />~ 22d. INJURY AT WO~{7 22e. DESCRIBE HpW INJURY pCCURREp
<br />F ' ^ YES
<br />146. RELATIONSHIP TD DEClDENT
<br />Wife
<br />18c. DNTE (Mo., Day, Yr.)
<br />March 16, 2009
<br />STATE
<br />Nebraska
<br />77b. Zip Cvda
<br />68973
<br />onset to death ^
<br />=~~~~wcZ. -._...
<br />anut to death
<br />[~jy~~n,"~`~
<br />onset to duth
<br />I onset to death `~_~~
<br />~~~,
<br />18. WAB MEDICAL E)(AMINER
<br />OR CORONER CONTACTEp7
<br />^ YES ^ NO
<br />210. WA$ AN AUTOPSY PF,)tpORMED7
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE pF DEATH7
<br />^ YE$ p.R6'
<br />STATE 21P CODE
<br />238. DATE OF DFJITH (Me., Dry, Yr.) R48. DATE SIGNED (Mo„ Dey, Yr.) 24b. TIME OF pEATN
<br />~~ March 12, 2009
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<br />23b. DATE $1 p ( • Yr.) 23c. TIME OF DEATH ~ 24c. PRONOUNCED DEAD (Mo„ pry, Yr,) 24d. TIME PRONOUNCED OFJLD
<br />~v March ~~, "~OS~ 1:03 a
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<br />c 23d. To fhe b t or e, deem xcumd 8t the dms, deb end place ~ get 1'" 24s. On the beeia or axeminatlon 8nd/or InvastlgWan, In my dplnlon duth occurrrd
<br />C end due th ceuse(e tad. (Signrturo end riele) y$ 02 ~ et tin nme, date 8nd p18ca end due to the c8uaa(y atetM. (SlgnBturo end TIRs)
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<br />28. BAC O SE CONTRIBUTE Tp THE DEATH? R88. HAS pRGAN OR TISSUE DO BEEN CON$IOERED7 28b. WAS CONSENT GRANTEg7
<br />YE N [~ PROBABLY ^ UNKNOWN ^ YES 1p ~ Not Applidable N 28a Ie NO ^ YES ~.r10~
<br />27. NAME, TITLE D ADDRESS OF CERTIF7E (~1~Y$ICIAN, CORONER'S PHYSICIAN OR Cp NTY ATTORNEY T Pdnr
<br />Ryan D Crouch D_O. ~pC A1.pha Street Grand Island ~~6p~80t3
<br />28a. REOI$TRAR'S SIGNATURE
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<br />28b. DATE FILED BY REGISTRAR (Mo., Dry, YrJ
<br />MAR 2 3 2009
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