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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALThI'°JgI~Dt ~UN(AtiVt VICES; IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA:~~C.~,~'PXfk~F~L~Il/T h~1EALTN AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR:GI~AL,R~C~ $,; •. ',; ~
<br />DATE OF ISSUANCE •: ~.,1 s„ l ~- ~ ',
<br />STLCLl~LLFY P ~ • • ~' ~'
<br />12/01 /2009 2 o i o 0 3 2 a~ A,SS~SfiAN~T1~,~5'~AR~
<br />DEP,ARTM'ENT~QF,h~AN~•H il}A/D °.
<br />LINCOLN, NEBRASKA HL1M'~l'~~~I'~I~,j ° ,` 1,, • c.,'
<br />STATE QF NEBRASKA - DEPARTMENT QF HEALTH AND HUMAN SERVtCE~'~,r• • ,~ r?.r .~~•.' '\'~^; .. 09 02TZ1
<br />CERTIFICATE Afw 17FATH '
<br />.~v
<br />.~.
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.5EX 3. DATA OF DEATH (Mo., Day, Yr.)
<br /> Ter Lee Sickler Male November 2p, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (MO., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Broken Bow, Nebraska 62 November 29, 1946
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br /> 506-60-8187 HOSPITAL ^ Inpatient OTHER ®Nursing Home/LTC ©Hoapice Fad11ty
<br /> 8b. FACILITY•NAME (If not Instltutlon, glue street and number) ^ ER/Outpatlent ^ pecadent's Home
<br />
<br /> ~fld~l9!ar1dV0tl?r8115 Home ^ pOA ^ Other(SpsCHy)
<br />U
<br />w ec. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />
<br /> 9a. RESIDENCE•STATE 9b. COUNTY 9c. CITY OR TQWN
<br />~ Nebraska Hall Grand Island
<br />17 9d. STREET AND NUMBER a. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 73 KuesterLake 68801 ^ vES ® No
<br /> 10a. MARITAL STATUS A7 TIME OF DEATH ®Married ^ Never Married 106. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name
<br />
<br />v ^Married, but separated ^ Widowed ^ Divorced ^ Unknown LaDonna Moritz
<br /> 11. FATHER'S-NAME (First, Middle, Last, suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />m John Sickler Dorothy Brundige
<br />~-
<br />E 13. EVER IN U.S. ARMED FORCES? Giva dates of service ff Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, ND, Dr unk.) Yes 01/24/1967-10/02/197p LaDonna Sickler Wife
<br />d
<br />a 15. METHOD OF DISPOSITION 16a. EMBALMER•SIGNATURE 16b. LICENSE ND. 16c. DATE (Mo., Day, Yr.)
<br />H ®8urlal ^ ponation
<br />Derek Apfel
<br />1240
<br />November 23, 2009
<br /> ^ Cremation ^ Entombment
<br />
<br />^ Removal ^ Other (Specify) 78d, CEMETERY, CREMATORY QR OTHER LOCATION CITY /TOWN STATE
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADpRESS (Street, Clty or Town, State) 17b. Zip Coda
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> AUSE ee ins ructions and exam lee
<br /> te. PART 1. Enter the chain of events--die9agga, InJurias, or compllca[lons-that directly Cauwd the death. DG NOT gntgr terminal events such ae Cardiac arrest, ; APPROXIMATE INTERVAL
<br /> respiratory sneer, or venirlCUlar nbrillativn without showing the edoldgy. DO NOT A66REVIATE. Enter only one Cauca on a Ilne. Add addhlonal Ilnee IT neCasaary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final al Alzheimers Disease ;Years
<br /> dlggasa ur Condttlon rogdllmq ~~ -~ ~.._ _ ... __ . ~_.., _ . ~ _
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> $equentlally list vvnditlona, If t))
<br /> any, Ieading'to !iw aauea listed
<br /> on hne a.
<br />DUE TO, OR AS A CONSEQUENCE pF: onset to death
<br /> enter the UNDERLYING CAUSE C')
<br /> (tllwasg or Inlury that Initlatgd
<br /> the events resulting In death) pUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 18. PART II. pTHER SIGNIFICANT CONDITIONS•COnditlons contributing to the death but not resulting in the underlying cause given In PART I. 18. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />tr
<br />w ^ YES ®NO
<br />
<br />LL 20. IF FEMALE: 21a. MANNER OF pEATH 21 b. IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMED?
<br /> ©Nvt pregnant wlthln peat year ®Natural ^ Homicide ^ DrlvarlOperator
<br />~ ^ Pregnant at time Of death ^ Accident ~ Pending Invea[leatlon ^ Passenger ^ YES ® NO
<br />
<br />a ^ Not prapnant, but pregnant wlthln 42 dayg of death ^ Pedestrian 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />©Sulclde ©Could not be determined
<br />•6 ^ Nvt prapnant, but pregnant ss pays to 1 year before death ^ Other (Specify) 70 COMPLETE CAUSE OF DEATH?
<br />~ ^ Unknown if pregnant within the past year ^ YES ^ ND
<br />a-
<br />c 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY ZZc. PLACE OF INJURY•At home, farm, street, facto
<br />ry, office building, construction site, etc. (Specffy)
<br />
<br />
<br />,~ Z2d. INJURY AT WORK? 22a. DESCRIBE HOW INJURY pCCURRED
<br />0
<br />~
<br />[] YES ^ NO
<br /> 22f. LOCATION pF INJURY -STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />~
<br />-
<br /> _ ga,,12A7~~ D~'~kl.{liCo., Dayr't`c.#= ~~`- "" - -" - " ~ ~ 4a. DA7~ SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> ro W November 20, 2009 ~
<br /> ~ ~ r 236. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH ~ ~ ~ r Z4c. PRONOUNCED DEAD (MD., Day, Yr.) 24d. TIME PRONOUNCED pEAD
<br /> E ~ ~
<br />z November 23, 2009 09:45 AM ~
<br />E
<br /> p ad.TO.tM belt of,gy krrowkdgs, death occurred at the dma, date and plea
<br />and due to the cauke(s) grated. (Signature and Tide) ~
<br />$ ~ O
<br />~ x pqe• On the basis of e%aminatlvn andPor Inveatlgatlon, In my opinion death occurred at
<br />
<br />F W
<br />~ p u the lima, date and lacsanddue to tna Cauca al grated. (SI
<br />p ( gnaturo and Title)
<br /> ~ Gene L. Wyse, DO ~ ~ ;
<br /> 25, Dlp TOBACCO USE CONTRIBUTE TO THE DEATH? Zea. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREp? 266. WAS CONSENT GRANTED?
<br /> ^ VES ®NO ^ PROBABLY ^ UNKNOWN ^ YES ®NO Not Applicable IT Zee la NO ©YES ^ NO
<br /> 27. NAME, T E F H I R A ype or riot)
<br /> Gene L. Wyse, DO, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 286. DATE FILEp BY REGISTRAR (Mo., Day, Yr.)
<br /> November 25, 2009
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