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¢2f. LOCATIpN OF INJURY - 9TREET & NUMBER, APT. NO. CITY?OWN STATE aP CORB
<br />23a. DATE OF 9EATH (Mo., Day, Yr.) 24e. DATE SIGNED (AAO., Day, Yr.) � 24b. 77ME OF DEATH_
<br />.�� dG�O�A'� -3i �4Q� � ��i m
<br />W� 23b. DATE SIONED (Mo., Day, Yr.) 23c. TIME OF DEATH .��! y O 24c. PRONOUNCED DFAD (Mo., Oay, Yr.) 24d. TIAAE PRONOUNCED DEAD
<br />T �
<br />4 0 .�.`LC�C� � .Z2 cT m E� a p R1
<br />V 23d. To the best M my Imowledge, death axurted at tfie tlme, date and place � W� 24e. On the basis W exam(natlon andlor Imeettgetion, In my opinlon death oecurted
<br />� p an d d t o e caus ( S i g n a t u r e an d T I Ue) , g 2� a t t h e tl rt re, d a t e a� M p l a ce an d d ue M the cause(s) e t e t e d (SiB�a4ue a r M T(tle)
<br />~ � �� u 1`�l(�,�.��I� f "` � � � V
<br />�J ~ c�i`o
<br />�8. DID TOBACCO USE CON7RIBUTE TO THE DEATH9 28a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED4 28b. WAS CONSENT GRANTED7
<br />�' ❑ YES ❑ NO ❑ PROBABLY UNHNOWN ❑ YES �:� NO NMAppllcaWe If 28a te NO ❑ YE8 ❑ NO
<br />'f7. NAME, TITLE AND ADDRE�8 CERTIflER (PHYSICiAN, PHY8ICIAN ASSISTANT, CORONER'S PHYSICUIN OR COUNTY ATTORNEY� (Type o ` Pri�M)
<br />� �. b. 1�.� : r ,M p L� 1�G t� . �� :� 4 �,,,�1 iys W. tl, �V� S
<br />2&a. REQISTRAR'S SIGNATURE ' � � 2Bb. DATE FILEO BY RE6ISTRAR (Mo.� DaY. Yr.)
<br />P ,�. ocT � � Zaos .
<br />��
<br />i6
<br />STATE OF NEBF�ASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUM
<br />THE BELOW TO SE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DERAR7%'i!'!
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO � VI7'AL RE�OR��
<br />. /I.f��rd':� ./�^�a.
<br />DATE OF ISSUANCE
<br />� OCT 1 � � 2009
<br />� {�, LtNCOLN, NEBRASKA
<br />i'o . --�----
<br />1. DECEOENTSNAME (Flrst, Middle, Laet, SWHx) °°"
<br />Wilner Ray Hotder Sr
<br />0. CI7Y ANO STATE OR TERRITORY, OR FOREI6N COUNTRY OF 81RTH
<br />STATEAF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC@'d �1;
<br />CERTiFICATE OF DEATH ��
<br />a
<br />N
<br />r
<br />�
<br />a,
<br />a
<br />�
<br />O
<br />V
<br />�
<br />O
<br />F
<br />� ❑Unlmoam H pregnvrt wNhln the past year
<br />m
<br />a
<br />o �,i22a DATE OF MJURY (Mo., Day, Yr.! - 22b. TIME OF INJU[tY 22c. PLACE OF INJURY-At home, term, atreet, tactory, otflce bullrIIng, cor�WCtlon sHe, etc. (Speelip) ..
<br />p - - m __
<br />0 22d INJURYAT WORK? 22a DESCRlBE HOW INJURYOCCURRED
<br />f' ❑ YES ❑ NO
<br />Grand Island, Nebraska
<br />T. SOCIAL SECURRY NUMBER
<br />505-3�-�9 9 �i _ _ _ -- - - --
<br />8b. FARILITY-NAME (If rwt Instltutlon, giva atreat and rtumbe�)
<br />' Saint Francis Medical Center
<br />Bc. CITY OR TOVYN OF DEATH (Include Ztp Code) '
<br />Grand Island 68803
<br />ea. r�sro�uce-sra� e�. counm
<br />,� Nebraska Hall
<br />9d 37REE�AND NUMBER
<br />619 E Meves Ave
<br />10a. MARITAL STATUS AT TIME OF OEATH � MacHad ❑ Never Me�
<br />❑ mamea, n�e seaereted Q wnaowaa ❑ o�wrcaa ❑ unimmxn
<br />17. FATHER'&NAMB (Flret, AAiddle, L�f; Su(f�c)
<br />18. METFIOD OF DISPOSITION 18a EAEBAI.MER-8IONATURE
<br />�°'°'e' �°°"e"°" Not Embalmed
<br />�c�uo^ pe�ro��e
<br />��� ��„ '18d. GEMETERY, CREMATORY OR OTHER LOCATION
<br />Centrat Nebraska Cremation Services
<br />77a. FUNERAL HOME NAME AND 6AAILING AO�RESS (Streat, qty or Town, Stam)
<br />All Faiths Funeral Home, 2829 S. Locust Street, Grand Island, Nebraska
<br />/ZCES, ,TI' CERTIFIES
<br />,NEALTH ,4ND
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<br />N�
<br />?' Y � S �-1�
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<br />�d ' '�
<br />y .1
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<br />c y n� .. .
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<br />��Q_ Q ;
<br />2 0�.10 4 4 7 3 . ���� ������: ��
<br />� : ';��� X ,,,,����
<br />._--- -- -_ :\, � '.
<br />� ' er'� '��; „� '.a
<br />Male
<br />6a AGE-Laet Blrthday 6b. UNDER 1 YEAR 8c, UNDER 1 OAY .
<br />(Yra) MO& DAYS HOUR9 AAW&
<br />79
<br />ae. auce oF nea�rr�
<br />.... x 'Y
<br />October 3, 2009
<br />8. bATE OF HtRTH (Mo., Day, Yr.)
<br />July �0, 1930
<br />-- -- - - t���r!st: � m __ -or,a�r.:'Li r��te� wum� ve - - � rt�p��,
<br />� ER/putpetlmii � DecedeM s Home
<br />❑ Qoa ❑ otneKs�rl
<br />8d. COUNTY OF DEATH
<br />Hall
<br />8a CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO. 9f. ZIP CODE 9g. WSID@ CITY UMITS
<br />68801 � r« ❑ No
<br />10b. NAME OF SPOU8E �flret, Mldme, Last, SuHix) N wHa, give matden name.
<br />Sandra Jane Thurber
<br />72 MOTHER'&NAAAE (Fpaf, EAiddle, Maldan S�unama)
<br />13. EVER IN U.S. ARMEO FORCE37 Ghre datas of seevice ff Yea 1Aa INFORMANT-NAMB
<br />(Yes, No, or unk) Yes 02/14/ 951-10/08l1956 Sandra Jane Hol�
<br />IMMEDIATE CAUSE
<br />IMMEDIATE CAUSE (Flnal ;^1 � ''
<br />rllsease or condltlon resultlng a) ,G2 4a � � V^ �'p �` K y�
<br />In death)
<br />DUE TO, OR AS A GONSEQUENCE OF:
<br />Sequentlally llst wndltlons, N b) �� t�,p� wa,/ � Q y�,�
<br />m�y. i�n�e w tire �se u�a o
<br />on Ihre a. DUE TO, OR AS A CONSEQUENCE OF:
<br />EMer the UNDERLYING CAUSE cJ ��� ��� G��bY�
<br />(dlsease or �njury that inidafed � �
<br />�the eveMs reauitlng In daath) DUE TO, OR AS A CONSEqUENCE OF: �
<br />L113T
<br />18b. LICENSE NO.
<br />cmROVUN
<br />Gibbon
<br />CI�Y9�� �� �ca�►Ti � j��� onsi�ructions and example:
<br />1B. PART L EMer the clreln Maveirta . d(ee�¢0. inluries� m eompUeatlona-Utet direetlY teueed tlre death. � NOT eMef [emUnai esenin weh ae eafmae ertest,
<br />reaPlreMiY ertes4 m ra�ttrhu[arflBrllleflon without BhwAnB the etiology. DO MOT ABSAEVIATE EMet onty MIe eeu8e on a M& Atld edUfUOnel Mea V rtaeeamry.
<br />14b. RELATIONSHIP TO DEGEDEWT
<br />18c. DATE {6Co., Day, Yc)
<br />October 5, 2009
<br />srare
<br />Nebraska
<br />17b. 21p C
<br />68801
<br />� . .........,..................
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<br />� otlsettodaeth
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<br />� �°w`� C`'
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<br />�onsmtto deadt
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<br />; onsee m aeau,
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<br />� onset ro tleath
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<br />,18. PART p. OTHER SIONIFlCANT CONDITIONS�ComAtlorm contrtbutl� to tlre deatb but rrot reaWtl� In the underiping causa given in PAItT I: 19. WAS 06E6ICAL EXAMINER �
<br />A L��•�- - ��Q � G �'� S' �QK,�Q,� � 4 . OR � oACTED?
<br />�
<br />W ', 2p, IF F'�MALE; 27a 6AA�dNER OF DEATH 216. IF TRAN8PORTATION INJURY 27a WA9 AN AUTOPSY PERFORMED7
<br />F � Not pregnant within pest yeer �Naturat ❑ Hatnicide ❑ Drived0µaretor ❑ YE8 �NO
<br />U �� Pregnent at tlme of deeth ❑ AccideM ❑ Pendi� Investlgatton ❑ Passe�er �
<br />NM PYe9rtaM. but P��� ��n 42 daya ot death ❑ 8uldde ❑ Could not be detertN�red ❑ Ped�Man �d' 44ERE AUT6PSY FMDINt98 AVNLABLE
<br />a �pNot pregnant, but pregnaM 43 days M 1 year before tleath ❑ Other (Speeffy) TO COMPLETE CAUSE OF DEATH?
<br />❑ YE9 ❑ NO
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