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. . . .. . . . .� ro � „�,* . . ... .
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<br />_ �,,,. .� STATE OF Nf�RA�KA ��� �� � ,» �, :
<br />. . � Y �:..�� k . � ' .
<br />f WHEN TH76 COPY�ARRIES THE R.4ISED SEAL OF THP NEBRASKA DEPARTMENT QE'1-!�,„ '� � � x �., Tf CERTIFiES
<br />THE BELOW TO BE A TRUE CORY �F THE ORIGINAL RECORD ON f1ZE WITH T/� lVE � TH AND
<br />NUMAN SERVICES, VITA! RECORDS OFFICE, WHICH ISTHE LEGAt DEPOSITC7�tY �� `�' � `°'
<br />. . . . . . � � Y �S� 1 .Y{� � '. � # � E.t��f�J . . . .
<br />DATE OF ISSUANCE � ��
<br />201i0274Q ��� ` � �������*�
<br />� �� � 12/01 i2009 � � »,�� n, ; � ° :
<br />d�P
<br />� LINCOLN� NEBRASKA � � � HUIN`��l , ��°� ` r � � �
<br />.,. ;•
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE9" � '�'� �' ^" Q9 0272�
<br />CER'TIFICA7E Of DEATH ' ,, �= �`';-�
<br />t. DECEDENTS-NAME (First, alWdfe, Last, SuMlz) 4. SEX J. DATE dP DEATH (Mo., Day, Yr.)
<br />Ter Lee Sickler Male November Z0, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREKiN COUNTRY OF BIRTH Sa. AOE • Last Blrthday b. UNDER 1 YEAR So: UNDER 7 DAY B. pATE OE QIRTtI (kb., Oay, Yr.)
<br />(Y►8•) MOS. DAYS HOURS NqN3.
<br />Broken Bow, Nebraska 62 November 29, 1946
<br />7. SOCIAL SECURITY NUMBER ," 88. PLACE OF DEATN
<br />506-60-8187 �❑ Inpatlent OTHER � Nursing Mome/LTC � Hospi�e FaciMiy
<br />8b. FltCILiTY�NAME pf not I�tttution, �Ive titreet and numbe� ,
<br />0 ER�Qutpatknt ❑ DsaedanPs ►lome ` � ._'
<br />w _ .... . . ° _,,
<br />� Grand dsland Veterans Home " ' � poA ❑ aner tspe�yl :�_ �
<br />� •
<br />� Sa C{TY OR TOWN OFDEATH pnclude Z� Code) ad. COUNTY OF pE4TH ` '` •
<br />3 Grand Island 68803 Hatl
<br />� 9a. RESIDENCE-STATE 9b. COUNTY 9e. CITY OR TOWN
<br />w Nebraska Mall Grand Island
<br />LL 8d. STREES AND NUMBER . APT. NO. 9f. 21P CODE 9p. MI&DH CI'fY UMNTS
<br />� 73 Kuester Lake 68801 ❑ res ��o .
<br />a t0a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Nwer Bi{aniad 70b. NAME OP SPOUSE (Rirst, Middle, l.ast, Suffix) If wlfe, give maiden name "
<br />� � ❑ nna�.�.a but sepawted ❑ Widowed p�.�a ❑ u�ow� �aDonna Moritz
<br />� 71. FATHER'S-NAME (First, NNddle, Last, SuHix) 12. AAOTHER'S•NAME (Ftrst, AMddla, Maiden3urname)
<br />� dohn Sickler porothy Brundige
<br />� 1S. EVER IN U.S. ARMED fORCES4 f3Ne dates of sarvics if Yes. 14a.lNFORMAN7•NM�IE 146. RELATIO17StNP TO OF�EDENT
<br />s (Yes, No, or Unk.) YeS 01/24M 967-10t02/197Q LaDOnna 81�icter W►fe
<br />,g 15. METHOD OF DISPOSITION 16a. EMBAIMERSIGNA7URE 16b. UCENSE N0. 'l6c. OATH (MO., Day, Yr.)
<br />F ? ��urfal ❑ oo�a�on perek Apfef 1240 November 23, 2Q09 �
<br />❑ Cremation Q Entombment ��y �EMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Re�o�i ❑ a� fsp�r) Grand lsland City Cemetery Grand Isiand Nebraska
<br />1Ta. PUNERAL HOAAE NANIE AND MAILING ADDRE33 (Street, City w Tbwn, $tate) 17b. Zip Cotla
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />ruetions a exam es
<br />�„
<br />� 7E. PART i. EMer dx ehaln M avents••diaaessa, InjurM, or co�npllcationstMt tlksdly causM iM depp. DO NOT �Ma termMrl �venq suoh ai urdiaC arrost, �; APpROJCIMATE 114'CEilVA1. � �
<br />respirawry arraat, or verteriemx flbriNatlon wqhout shewing pw atiolopy. DO NOT ABBRENqTE Eert�r only one eausa an r Une. Atld aAtllGoa� Bnes If neeeseary. �. � �. . . . �
<br />IMMEDIATECAUSE: ; ontytb�BBth
<br />� IMMEDIATE CAUSE (Fh�ai a; Alzheimers Disease . � . . ; : .� �. j � � � ; ... . ; ��rs. ; . . � .� �
<br />_.. . uianase a Contifelon �►EnMr�g' . .. �. . � _. . . . . >.+ �� , .. , .. � _ >a....+ _.._.,..`., _ -++'. - .. . . ._ 34a. • ;ga.a ^'-- . '..g�._� +, .,' _�.,>� .:�3..w - - e i� �
<br />9 . ._ .. . . _ . . _. . _
<br />� In death) . - . . . • . .>`.::
<br />DUE 70, OR AS A CDNS@LIUENC� pF: : or�ist to tPaaYr
<br />Sequentialry Rat co�itionq it b) � � .� ' � , � � � .. �"; � � � � Y � �"`.
<br />any, leadiny to thB uuse Ilated . � � .� .. . . . � . . : . . . � . . . . ..
<br />onnnea. , ,A. , , � i
<br />DUE TO, OR AS A CONSEQUENGE F.' � , • ens�t to dePN�' ^ •
<br />- Entar the UNDER4YMIG CAUSE C � . . . . � � • � . � � ' � . � ' . ., .
<br />Av
<br />� (diseaae o� INury tlwt lnitiated . � ��:� . `•:*. �. •� , . � . . .. .
<br />ma evems �uldrw � deam� DUE TO.OR AS A COMSEQUENC� OF: : o�vt to death �' �
<br />tAST d � . , � � . . . � , � . Y � � "t' . ,
<br />a� ��
<br />. . . . . .. _ �y . ..
<br />!
<br />18. PART II.OTHER 51GNIFICANT CONDITIONS�COndttbns cont�ibuttnQ to the death but notresultin4 tn the underying causa glven hi PAtrf i. 18. WAS MEDit�Yi'F�tMAfN�R"
<br />OR'CORONER�ONTACT6D?
<br />� C] YES . � NO
<br />LL , 0. IF FEMALE: 21a. MAPINER OF DEAikI 21b.IF TRANSPpRTATiON Ip13U 27c. WAS ANR �PSY PEfiFOR1�D7
<br />F . � Not pre9nant within P� Year . . � � NaNral .� � Homicide . . � . .� OriwAOpwaMt .. . . ��
<br />o ,�g � No
<br />� � .� Prepnant attime of desth � � � Act(OeM � PerlOhtQ-inve�Rl9etbn ❑ PatMnOw � . . � . . � � �� �. � .. .
<br />T � Not pnpnaM, bu[ piegnent within 42 Ory6 of death [J waesaun 21d: WEREAIYTOPSIf FU�iNCiS AVNtA6
<br />� [] swdas Q coum �se b. e�t.mde�.d TO COMPI-ETE CAU3E �F DERTH?
<br />� Not propnant, but preqnant 41 days to 1 year bekro deaM .. - -� Q:�hsrj3p�dy� �
<br />� � Unknown if prapnpM withM the past Ywf �. . �. � . �. . . . �� Y � . � � . Q � � . .
<br />�" 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TlME OF tNJURY 22a. PLACE OF.INJLRY�At home, farm, streat, �ttoFy, oHlce buiWing, constructfOn sits, ete. (Spe�ify)
<br />E `
<br />�
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HQW INJURY OCCURRED
<br />I C - � . . � �. �.. � . . . � � �:..
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY •$TREET 8, NUMBER, APT.NO. CITY/70WN . S7'ATE' ; ' ZIP CODE
<br />. �,_�__ ..
<br />28a. DATE CIE-DG-r:�f1:l1No„"F3mY� YrP� -• ^., . :} II�W. AATE 316NED (Mo., Day, Yr.) � 24M. TMA@ OF DEATH
<br />� �'.� November 20. 20b9 ., , ,� �
<br />` ��} 23b. DATE SKiNED (Mo, pay, Yr.) 23c.T1ME OF DEATH ���} 24c. PRQNOUNCEO DEAD (Irb., Qals,1lr. 24d.1NY1� PR QEAD
<br />�__. - W Nt�Yami�er 23, 20 .09:45 AM , ¢ , ; ,
<br />�._ _ . :
<br />�_,.�_ , o . . � r
<br />o S w. ro en� Bsn a mvknwvhd�Pi, waU� ouueASe at awawn., w an,r , Q ac�e+�:sww-�e+6eaingq+eM� w u-��1 ���, .
<br />8 � am! dw tQ LM quaefslBUteU. iSIpn7R4M �ntl TRk1� � . ���. � � tha Lme� tMte and P�ace &Id d� t(i dl i�Se Ea� a. t e�n " _.., :�
<br />�
<br />~ � , Gene L. Wyse, DO � 8 g . _ ` . _ �
<br />2S. DID TOBACCO USE CO RIBU TO TH� qEATH? 26a. liA3 ORG OR 3P3SVE DON TIOM B EN CONSIDERE ?< 26b. WA8 NSEN GRqfl ?- '. �
<br />C7 YES � NO [� PROBABLY �] UNKNOWN ❑ Y�S � NO Not Appilcibie tf 26a la NO YE3 Q� °
<br />. Yi� 4f
<br />Gene L. Wyse, DO, 2300 West Capitat Avenue, Grand Islactid, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 2db. DA'fE FILED EY R�p�S1'RAk�MO:� tlp�; Yr.}
<br />November 25, �009 '
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