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<br />STATE OF NEBRASKA
<br />WHEN 7HIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT QF,H�LTH AND HUMRN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE N�`BR�QSKA �f.?�B�T�?�NT OF HEALTH AND
<br />r HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEP05ITORY FI7R _V�'`AL,I�,���R�� �, r a' ,
<br />�
<br />DATE OF ISSUANCE
<br />(� q (!r _;, 6 . �^ wr�' .
<br />J a� d O ZW7�7 �G V � 1 O V a� � � .�Te���'IL�Y �. 'COOP�R ; 'y; � � , ;
<br />� a '�41��"I�5'TANT SF.�7'�' 1�''EGI'ST�kR `� „ " �
<br />° � ��t�,�+�4RT 3��'�FI�•Ft'G?'�laN'!�
<br />• LINCOLN, NEBRASKA � _ , '��(-1�1i,1N d��F�C�5. �.� p�
<br />STATE pF NEBRA9KA - DEPARTMENT OF HEALTH HUMAN S�W�@ES �'� '
<br />CER71F CAT O E H ,�' � �' •..��� ��� �� ��� 6 '
<br />�. oeceoeNrawmae � (�rs+, nuame, �.aeR sumxl ; a s� �, � ���, '� � ,' t ��
<br />� �� , r � e - e�' . . . , . t .v '
<br />Robert Lee Wissel ` Male `° � � � Jl�n�t -ry4, 20�1�9 � ' ,
<br />4. CIiY AND 87ATE OR TERRITORY, OR FOREIpN COUNTRY OF BIRTH Ba ApE-Last Bltthday 8b. UNDER 1 YEAR 8a. UNDEI�1 DAY �' "�. `pq'�!QF BIR'F�`'(p8o Day, Yr:) '�
<br />(Yra) dIOS. DA1fS HOUR$ MINS. � � k �' .
<br />Beatrice, Nebraska 80 July 71, 9928 \ .
<br />7. SOCULL SECURITY NUWBER � 8a PLACE OF DEATH
<br />506-24Q873 Hosrrrn�: 0�aem OTIiF_R;� Nasing Hom�I.TC [� Hospiae FaciUty
<br />U 8b. FACIL7Y-NpME pf not InsUtWon, giva etrae¢ entl mimber) � ERfOutpetleM � Deeedem�s Home
<br />� _ - - '" --- - ` _
<br />d 1429 Stagecoach Rd - ❑ D°^ ❑o��csa�r� -----, -- -- --
<br />8c. CITY OR TOWN OF DEATH (6rclude Zlp CodeJ 8tl. COUNIY OF DFATH
<br />Grand Island 68801 Hall
<br />� 9a RESIDENCESTATE 8b. COUNTY 8c. C(TY OR TOWN
<br />LL
<br />� . Nebraska Hall � Grand Island
<br />�p 8d. BTREET AND NUMBER 9e. APT. ND. 8t. ZIP CO�E 8q. W8lDF CITY IJtd!'f9 �
<br />df �
<br />� 1429 St�gecOach Rd 6$gp� � vea No
<br />� � � 70a MARRAL STATUB AT TIME OF DEATH � Martled [] Never AAartied 10b. NAdIE OF SPOUSE (Flrst, AAiddle, Lest, SuHin) If wHe, glve ma�dan �, �
<br />� � ae�ea. euc seaara+ea ❑ unam,wea ❑ o�„crcea ❑ u�a,own Patricla Eloise Lindgren
<br />�' 7l.FIiTHER&NpAAE �
<br />� (�, Mlddle, Lesl, SWfix 12 A70THER'&NAME (Flrst, � Mlddle, � MaideA Sumama) .
<br />� Alfred G Wissel Rachel Walfoord
<br />� 13. EVER IN U.8. ARMED FORCE87 �Ive dates oT aerWce H Y�. 14a WFORMANT.NAAAE 14b. ItEU►TIONSHIP TO DECEDENT
<br />F
<br />(Yes, No, or unk) No Patricia Vllissel Wife
<br />18. mETHOD OF OISPOSITION 1 BALMER-St RE 186. UCENSE N0, 18c.17ATE (INo., Day, Yr.►
<br />�BUr1+U �Do�tlon 1 . .
<br />��,�,,,,,,, ��,,,,,,�,,, r /� 7� Janua 8, 2009
<br />��� �� 98d. CEI�ETERY, CttEMATORY OA OTHER TION CITY/TOWN STA'1'E
<br />Hickman Cemetery Hickman Nebraska
<br />17a FUNERAI: HOME NNHE AND MNLINO ADDHE38 (Street, City or Town, Stete) ' 17b. Zip Cade
<br />AlI Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 88801
<br />CAUSE OF DEATH See instructions and examples)
<br />18. PART L Enler Ne theln af evenm .�� InL+riee, or wmplieatlom-tlmt tlimqly aausetl fire deaM. DO NOT aMarlBmtlnel avanb sueh es eaMaa erteet, APPROXIMATE INTERVAL
<br />�eaPlBtnrY er�! mrsatrlwlerNbrAletMn wNhart nMring flre edolegy.00 NOT ABBREVIATE EMer onh orre eauea on a Wre. Atld atldlNOna� Il�rea H neceseery. � .
<br />_ _ _ ne
<br />_ . - -- - - -�- --�- - �- s- -�_. _.____..
<br />IMAAEDIATE CAl18E: _ - �� onset to death
<br />WIMEGIATE CAUSE (Flnel ' �
<br />dlaease or coMdMion resWtlng a) i
<br />indeath) cardiac� arrest � nkno n
<br />DUE TO, OR AS A CON8EQUENCE OF: � a � � d��
<br />SequeMlally Ilat co�ido�re. H �
<br />a�ry.leamngtoUrecauaepated b � COPD ' unknown
<br />on Itne a. DUE TO, OR AS A CONSEQUENCS OF: � a � � d�th
<br />t
<br />i
<br />� Enter fhe UNDERlY1N0 CAUSE a) � ,
<br />(�e w inJury that Inttlated � � � .
<br />the evenffi rasul8� in death) DUE TO, OR AS A CONSEQUENCE OF: � onaet to death
<br />LAST �
<br />i
<br />d) � i
<br />1& pART R OTHER SIGNIFICANT CONDITIONS-Condiflo� contributl� W the death but not reaulting In the underlying cauee gtven in PART L 19. WAS MEDICAL EXAMW ER
<br />OR CORONER CONTACTED9
<br />P$ rES G] NO
<br />� Y S
<br />LL 20. �F FEd9ALE. 27a MANNER OF DEATH 21b. IF TRqNSPORTATION �NJURY 21a WA3 AN AUTOP81' PERFORMED7
<br />� [] Not pregnant withln past year � NaWral ❑ Homlcide ❑ briraNOparaMr ❑ YE9 �NO
<br />❑ PreBnant et tlme of tlaelh ❑ Aacitlent ❑ Pendin8 Imestl9adan , ❑ Passenger
<br />❑Not Pre9rteirt. but pragnmtt wfWtn 42 a�s MdeaUt ❑ Suktde ❑ Could rtot be delemUned 27d. NfERE AUTOPSY FINDWGS AVAILABLE .
<br />� � ❑ p��� TO COMPLETE CAUSE OF DEATHT
<br />❑ N� P�B�e�k � P�M � deys to 1 yeaz betora death ❑ pthe� (Bp�HY) .�,(
<br />� DUnknown It pregnant wkhin the paet year ❑� A�NO
<br />m
<br />a
<br />0 22a DATE OF INJURY (AEo., Day, Yr.) 22b.17ApE OF IW URY 22a PLACE OF INJURY�11t home, tartn, atreet, factory, office bWldtng, eonatruetlon alte, etc, (Speelty)
<br />t
<br />0 2Zd. INJURYAT WORK9 22a. DESCRIBE HOW INJURY OCCURRED _ ----- -
<br />F -
<br />❑ YES ❑ NO - _ _ =- - --- - _- -- _
<br />22L LOCA770N OF INJURY - STREET $ NUMBER, APT. NO. CITY/TOWN gTp7E bp �ppg
<br />7, 23a. DATE OF DEATH (AAo., Day. Yr.) 24a DATE 810NED (Mo., Day, Yr.) 24b. TIME OF OFATH
<br />�t�.l � - . .��� • �191
<br />��} 23b. DATE 816NED (Mo., Day, Yr.) Z3c. NdE OF DEATH � y�� Z4c, pRONOUNREO DEAD (INo., pay, Yr.) 24d. TimE PRONQUNCED DEAD '
<br />Z
<br />� �o m E Na o January 4, 2009 �9:2�6 a
<br />� y 23d. To tha tr�f o! mylmawledge, dsath oacuned at y�e dme, tlate aynl pleee s W� 24e. On tha basls o} ezaminatlon and/or inveatl8etlon, In my opinlon death eccurted
<br />F� end due to the cauae(e) sfat�i. (Signature �nd 17t1e) ��� at the �e� �� a� �p due to tlre �e(s) �. ($i�due at�d ntle j
<br />0
<br />�� Hall Count Attorne
<br />�, 26. OID TOBACCO USE CONTRIBUTE TO THE DEATH7 2Ba. HAS ORGAN OR TISSUE DONATION BEEN CONSID 20b. Wq8 CpNSENT ORANTED?
<br />❑ YES ❑ NO ❑ pROBABLY � UPIKNOWN ❑ YEg � NO Not pppUcabte if ZBa te NO [� YE8 ❑ NO
<br />27. NAME, TITLE AND ADORESS OF CERTIFlER (PHYSICUW, CORONER'S PHYSICfAN OR COUNTY ATTORIYEY) (Typa or PdM)
<br />Mark J. Youn liall Count Attorne 231 S. Locust Street Grand Island NE 68801
<br />2Ba REOlSTRAR'8 SIONA7URE Z86. DATE FlLED BY REGISTRAR ( Nlo.� �aY� Yr.)
<br />� a• JAN � $ 2009
<br />1
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