|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF 7'NE NEBRASKA DEPARTMENT OF HFAL'�ld�A+��UM11A�• IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASI�A ��IRT,I!��T c� �F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS pFFIC�, WMICH IS THE LEGAL DEPOSITORY FOR �/IT�f'L`74EC�S �
<br />� �'' '
<br />DATE OF ISSUANCE ���'',�`
<br />��r�� �.. . M
<br />11 /02/2010 � Q 1 � (� S 4 � � s5 �r� s �� ���"Grsrka� ,'
<br />DEP,WRTM����HEA1�f�i� AI�D ,•,
<br />LINCOLN, NEBRASKA IiUI�;AIV SE/:VIC�S, •' ' ^y'
<br />S7ATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES, ���,�',�'r� ��� � �;�r� u � ' 10 03107
<br />AG�TICIf� ATC AC 1'1C ATLI 7 �. C' .. ' ... .. ...
<br />VV�\����VA��Y� VFA�1� '/
<br />1. DECEDENT'S•NAME (Flr�t, Mlddle, Last, Sufflx) 2. SEX ' a�� � ATE OF Q,�1effH (Mo., Day, Yr.)
<br />Llo d Arnold Willkens Male "" Oct�ber 19, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN GQUNTRY OF eIRTH Sa. AGE • Last Blrthday 6. UNDER 1 YEAR 5c. UNpER 1 DqY e. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) MO5. DAYS HOURS MINS.
<br />Amherst, Nebraska 85 Ma 12, 1925
<br />7. SOCIAL SEGURITY NUMBER Ba. PLAC� OF DEATH
<br />506-20-4998 �@� � Inpptlent OTHER ❑ Nunlnp HomaILTC � Hosplca Facllily
<br />86. FAGILITY-NAME (H npt Instltutlon, pNa streat and number) [] ERIOutpatiant ❑ qecadanNs Homa
<br />K
<br />� Saint Francis Medical Center ❑�A Q Other�$peclTy)
<br />U
<br />W 8c. CITY OR TOWN OF DEATH (Include Zip Coda) 8d. C011NTY OF DEATH
<br />K
<br />� Grand Island 6$803 Hall
<br />� 9a. RESIDENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 8d. STREET ANP NUMBER e. APT. NU. 9f. ZIP CQDE 8q. INSIDE CITY LIMITS
<br />�` 25 St. James Place 68803 [� res ❑ No
<br />� 10a. MARITAL STATUS AT TIME pF DEATFi � Married ❑ Never Marrled 10b. NAME OF SPOUSE (Flrst, Mlddle, Last, SuHix) H wBe, plva maldan nama
<br />!E [� Marrlad, but separated ❑ wiaoWSa ❑ Divorced ❑ Unknown 5arah Jane Foglond
<br />w
<br />� 11. FATHER'S�NAME (Flrst, Middla, Last, Sufflx) 12. MOTHER'S-NAME (Flrst, Middle, Maldan 8urname)
<br />� Car1 Herman Willkens Augusta Susennah Abels
<br />R 1S. EVER IN U.3. ARMED FORCE87 Glve datas of sarvlce If Yea. 14a. INFORMANT-NAME 746. RELA710NSHIP TO �ECEDENT
<br />E
<br />$ �vea, No, or unk.) Yes 04/05l1943-06l01/1946 Serah Jane Willkens Wife
<br />�' 15. METFIOP �F PISPOSITIDN 78a. EMeALMERSIGNA7URE 16b. LICENSE NO. 78c. DATE (MO., Day, Yr.)
<br />F ,�, � 8urlal � �ondtlon
<br />Daniel D Naranjo 1071 October 23, 2010
<br />❑ Cramatlon ❑ Entombment 78d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TbWN STATE
<br />❑ Removal ❑ Other (Specliy)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL NOME NAME AND MAILING ADDRESS (Straet, Clty or Town, SWte) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 5. Locust Street, Grand Island, Nebraska 68801
<br />AU E F DEAT ee instructions an exam es
<br />1E. VART I. EMar tha �}n of eventa--dlseaaae, InJurlea, or compllntlona-that dlrrctty cauwd thr drath. DO NOT rM�r trYminal aviM� �uch u CeYAlac afresl, ; APPROXIMATE INTERVAL
<br />resplratory ilre6t. OP vemdCUla/114rlllatlon wilhout ahowlnq thr otivlopy. DO NOT ABBREVIATE. EMYr only vrw cauw on Y Ilna. AtlA ad0lGOna1 Ilnas If neGSiiry.
<br />IMMEDIATE CAUSE: ; onset to death
<br />iMMeou,r� cnuse ��mm e) Aspiration Pneumonia ; Days
<br />dlssaes or cpndltlon nauklnp .
<br />In daNh) DUE 7Q, OR A$ A CONSEQIIENCE OF: ' nnset to death
<br />Srqurntlally Iirt Condltiont, IT b) Dy5phagi8 : Mqnths
<br />any, leadlnp to tho Cauar Iitlrtl
<br />on i�ne a. DUE 70, OR AS A CONSEQUENCH OF: � onsat to daath
<br />Entertha UNPERLYING CAU8E �) Cerebral Vascular Accident ; Months
<br />(dlwaW or InJury Mit InttlitYtl
<br />thr rwM� rosuttlnq In drath) DUE TO� OR AS A CONSEQUENCE OF: � onset to deeth
<br />usr d)
<br />18. PART II. pTHER SIGNIFICAN7 COND1710NS�Condltions eonmbutMq to tha daath put not rasultinp in tha underlying causa plvan In PART 1. 79. WAS MEDICAL EXAMINER
<br />Gastrointestinal gleeding OR CORONER CONTACTED?
<br />a ❑ ves p No
<br />W 0. IP FEMALE: 21a. MANNER OF DEATH 21d. IF TRqNSPQRTqTIQN INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />� � Not propnAnt wlthin pa8t yea� � Natunl � Hamicldr � OdwdOporYtoY � YES � NO
<br />U � Propnant at tims o� death � Accidem Q Psndinp Invealpal�on ❑ Paawnpar
<br />� Not preynam, but prepnaM within a2 days of dssth $�icidr Cauld not 6a dNsnnlned ❑ PodY�tdan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� � Not prognant, bm prounant as daya to � year bsran daath � � � Other (Sprclfy) TO COMPLETE CAUSE OF DEATH�
<br />� � unknown If prepnant wRhin the part year ❑ YES � NO
<br />°' 22a. DATE DF INJURY Mo., Da , Yr. 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, straat, facto ottice bulldl ( p Hy)
<br />� ( y � ry, ng, construcdon sita, atc. 8 ac
<br />$
<br />� 22d. INJURY AT WORK? 22a. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />�"' ❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYlfOWN STATE ZIP CO�E
<br />23a. DATE OF DEATH (Mo., pay, Yr.) � 24a. oA7E S1GNEq (Mo., Day, Yr.) Ydb. TIME OF DEATFI
<br />� W October 19, 2010 <- --- - t�
<br />� LL r 236. DAT� SIGNED (Mo., Day, Yr.) 29c. TIME bF DEATN �� 24c. PRONpUNCED DEAD (Mo., Uay, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� -+ October 29, 2010 08:55 PM � � ` �
<br />$ � 9d. Ta tha best of my knowledqa, daalh occurrad at tho tlmr, datr and placa $ pM. On thY W�I� of ixamination inNof InVeMlpatlon, In my opinlon death occurred at
<br />B� �nd dus to tha ausa(s) statad. (8lqnatun and Tttlr) g�� {ha tiny, data and placa and dw to tlw cauw�s) �tatrd. (51pniWrr ihd TItIB)
<br />~� Travis S. Hageman, MD ~ g o
<br />25. DIU TOBACCO USE CONTRIBUTE TO THE DEATHT 28a. HAS ORGAN PR TISSUE ppNAT1pN BEEN CONSIDERED7 266. WAS CONSENT ORANTED?
<br />� YES ❑ NO ❑ PRpeABLY ❑ UNKNOWN ❑ YES � NQ Not Applicable If 28a Is NO � YES [� ND
<br />, ypa or r n
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 688U3
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILE� BY REGISTRAR (MO., Day, Yr.)
<br />November 1, 2010
<br />
|