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STATE OF NEBRASKA
<br />WHEN THIS C�PY CARR7ES THE R.4ISED SEAL (7F THE NEBRASKA DEPARTMENT OF HEALTI�'f4�11D�'�LrN�A� VICES, IT CERTIFIES
<br />THE BELOW TD BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS'�C,�,(9B1�'S4 �jhIEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOI�,Vlxl@L R� �S.• •,'� �'�., ��
<br />DATE OF ISSUANCE � � P l�! ' �,. •� 1 , °
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<br />�MENT OF H�,q�T�G,�ANE�; �'
<br />LINCOLN, NEBRASKA Ht�J��,AI�',SE��VIC�'.� �' `�.;.',��' M � .
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<br />STATE OF NEBRASKA - DEPARTMENT QF H�ALATH D HUMAN SERVICES ����/ �� '
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<br />1. �ECE�ENTS-NAME (Flnt, Mlddle, Leat, Suftla) 2 SEX � 3. PATE OF CEAT �Mo.,�ay,Yr.) �
<br />Clarence Eu ene Welis Male October 19, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIaN COl1NTRY OF BIRTH 8a. AGE-Lsat Blrthday 6b. UNDER 7 YEAR bc. UNUER 1 DAY 8. UATE OF BIRTH (Mo., �ay, Yr.)
<br />(Yn.) MOB. DAYS HOURS MIN3.
<br />Orange City, lowa 83 November 9, 1826
<br />7. SOCIAL SECURITY NUMBER Br. pLACE OF oEA7H
<br />a 485-25-5568 tl9�P1IAL: � �nPetlsnt QjyE� [] Nuninq HomelL?C � Hoaplro Facllily
<br />� Bd. FACILITY•NAME pf not InatltuHon, give �treet end number) � ER/Outpetlent � Oecedent'a Home
<br />� Veterans Affairs Medical Center ❑ DOA ❑ aen.psp�ir,��
<br />a
<br />� Ba CITY OR TOWN OF DEATH (Include 21p Coda) Bd. COUNTY OF DE4TH
<br />W Grand Island 68803 Hall
<br />'� 9a RESIDENCE-STATE 96, COUNTY 90. CITY DR TOWN
<br />�
<br />�, Nebraska Hall Grand Island
<br />. 9d. STREET AN� Nl1MBER 9e. APT. NO. 9f. 21P CO�E 9p. INSIDE C�T'Y LIM�TS
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<br />� 2136 N. Park Ave. 68803 � v.. 0 No
<br />� 70tl. MARITAL STATUS AT TIME OF �EATH � Marrivd � Naver M�rtird 706. NAME pF $POUSE (FI1'st, Mlddl9, La�t, SuTflx) If wlfY, gW� mdd�n nam�.
<br />� ❑ Marrl�d, but �apsntad ❑ Wldawad ❑, plvorcad Q Unknown Bett Jane Gibson
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<br />� 71. FATHER'S-NAME (Flnt, Mlddle, LA�t, Su}flx) 72. MOTHER'$-NAME (Flret Middle, Mtlden Sum�ms)
<br />� Earl Sherman Welis 5 Ivia J Rookstoot
<br />m 73, EVER IN U.S. ARMEU FORCES9 GWe date� ot aervice H Ye�. 11a. INFORMANT-NAME 14d. RELATIONSHIP TO D�CEOENT
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<br />� (Yas, No, o. u�k.� Y Bett Jane Wells Wife
<br />76. METHOD OF �ISPO$ITION 1Ba, EM 4MER-SIGNATURE 18d. LIGENSE NO. 18c. �ATE (Ma„ �ay, Yr.)
<br />�aun�l �oon�non �
<br />� Octobar 22, 2010
<br />�Cf�m�tlan �Entom6m�nt
<br />������ ❑ � MnB ��� N � 10d. CEME7�RY, CREMqTORV OR OTHER LOCATION CI7YITOWN STATE
<br />Central Ciry Cemetery Central City Nebraska
<br />77a. Fl1NERAL HOME NpAAE AN� MAILING ADDRE88 (Sfreet, Glly or Town, State) , 17b. Zip Code
<br />Solt Funeral Home, 1507 17th Street, Central City, Nebraska 68826
<br />CAUSE OF DEATM See instructions and exam les
<br />�e. nnar i. enee� m. enu� d w.ne+ - dlNaw�, inJunu. or comptlwuons- tn�t aineny e�urd tn� Aeuh. p0 NOT mpr u�mind rwms �ucn aa araue amat, ; APPROXIMATE INTERVAL
<br />mplr.tory am.t, or wmAeuprnMlll.uon wlihoul �nowlnp iM �tlolopy. �O ND7 ABeReVIA7F. F�wr onty eM e�u.. en 11 Iinr, Add 1ldamonal Iinn M n�aeury. �
<br />IMMEDIATE CAl19E: � � � ; p�aet to dellth
<br />IMMEDIATE CAIJSE (Fina�
<br />dl�pae o� C011dltl0111'B6YIGnq 9)
<br />In deam) ��
<br />�UE TD, OR AS A CONSE UENCE OF: ; onset W deeth
<br />SepuenHally Iltt condltiona, I( b)
<br />any, luding ta th� aaqae IlEted
<br />on Ilne a. DUE 70, tlR p CDNSEpUE GE OF: � onas! to deeth
<br />Er1teY ttl� UNDERLYINO CAl19E C) � � \
<br />(dH�an or InJury thaf Inldelad "
<br />ma evenls roaultina In death) �UE TO, OR AS A CONSEQUENCE OF: � onnet to d�ath
<br />LAST
<br />d► e
<br />18. PART 11. OTHER SIGNIFICANT CpNUiT1qN9-Candldana cantq6ullnp to the death 6ut not ultlng �n the updaAy ng ceuee q ven In PART I. 79. Wq$ ME�ICAL FXAMINER
<br />OR GORONER CONTACTEU9
<br />d � � ❑ YE8 NO
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<br />W 20. IF FEMALE: 21p. MANNER OF UEATH 21b. IF TRANSPORTAriON INJURY 27c. WAS AN A�TOPSY PERFORME�7
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<br />� ❑Not propnant wlthin paat yeer atural ❑ Homlcida � Q oAVeqOperator ❑ YES O
<br />❑ Propnent et tima ot death ❑ Accldant ❑ pendlnp Invaatlpadan ❑ Paaaenpsr ��d, W�RE AUTOPSY FINOINO$ AVAILAB4E
<br />�"� ❑Noe pngn�ne, but prapnant withtn 42 days ot daafh [] Sulcid� ❑ Could nol da daterm�ned Q P�dned�n TO COMPLETE CApBE pF OEATH7
<br />�' ❑Not pnpnent but propnant 43 deys to 1 year 6aforc daath � Othar (SpeclTy) ❑ YES m'}JO
<br />� �Unlmawn Ii prepnant wlthin the paet year ��
<br />�
<br />� 22a. nATE OF INJURV (Mo.� Dey� Yr.) 22b. TIME OF INJURY 27c, pLqGE OF INJURY-At home, Tarm, �atnat, ►aclary, ofllca bulld�nq, connructlen dle, �lrs. (Speclty)
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<br />O 22d. INJl1RY AT WORK7 42a. �ESCRI6E HOW INJURY OCCURREU
<br />�`" ❑ YES ❑ NO
<br />2N. LOCATION OF INJl1RV - STREET 6 NUMBER, APT. NO. CITYITOWN STA7E ZIP CO�E
<br />29a. DATE OF �Eq7H (MO., Day, Yr.) �. 24n. �ATE $IONE4 (MO., OAy, Y�.) 24b. TIME OF DEATH
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<br />W C� � �U= IIl
<br />�� r 28b. DATE SIGNED (MD., I)Ay, YP.) 27c. TIME OF DEATH �� O 2Ac. PRONOl1NCED �EqD (MO., Day, Yr.) 2Ad. TIAAE PRONOUNCE� DEAD
<br />E�i m °"� �
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<br />23d. 7o tl�e ba�t a( my knowladpa, dsath occurrod M tha Gma, drta rntl plac� �� y p 2qe. On iha beflt oT examinatlan and/or Inve�tlqatlon, In my op�nian d�slh accurred
<br />o W wnd due to th� c�usa(a) slated, (Slpneturo end TINe) � Q O et tha tlme, dal� and pl+cs end due to the csu�e�q �taead. ($Ipneturo and Title)
<br />�� �+ � � pCV
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<br />26. �I� TqBACCQ US GON7RiBU7� TO THE DEATH7 28a. HAS ORGAN OR TISBUE NAT10N BEEN CpN$14ERE09 26b. WAS CONSENT 6RpNTEp7
<br />❑ YES ❑ NO PROBABLY Q 11NKNOWN ❑ YES Np No! Applicabls It 28e I� NO Q YE$ NO
<br />27. NAME, TITLE ANO ADDRESS OF CER7IFIER (PHYSICWN, PHYSICWN ASSBTANT, CORONER'S PHYSICWN OR GOUNTY ATTORNEY) (Type or Pdnl)
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<br />28u, REGISTRAIi'S 316NATl1RE � � 286. qATE FILEp BY REGISTRAR (Mo., �ry, Yr.)
<br />P � �. NOV 0 2 2010
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