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STQTE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVKES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGTNAL RECORD ON FILE WITH THE NESRAS�.�3EP� , R'�4U� OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR��I�L�L�R�Sr; f�� " �
<br />DATE OF ISSUANCE ��• Po �����(� �
<br />�������5!�� _
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<br />LINCOLN, NEBRASKA � O � � O � � v � ,Hl7h�AlV SER17 C _ ,,�
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<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN 3ERVICES Fl�E•A�Ft��llAPQRT �<.� o
<br />CERTIFICATE OF DEATH � ° • . . _
<br />,��` t. DECEDENT'8-NAME (Flrat, Middie, Last Suffix) 2. SEX 3.DATEOFDEATH (Mo.,Dey,Yr.)
<br />��', William Leroy Gannon Male Julq 18, 2008 '
<br />��` 4, CITY AND STATE OR TERRITORY, OR FOREION COUNTFiY OF BIRTH 6a. A�E-Laet Birthdey 6b. UNDER 1 YEAR 8c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />�4�" 44+ m (Yra.) M03. DAYS HOURS M�N3. �
<br />, Grand Island, Nebraska 60 September 10, 194
<br />7. 80CIAL 3ECURflY NUMBER Be. PLACE OF DEATH "
<br />506-58-8026 HOSPITAL: ❑ Inpatlenl Q� �I NursingHome/LTC ❑HoapicaFadtlry
<br />8b. FACILITY•NAME (I} not Inatitution, give street end number) ❑ ERJOutpetlent ❑ Decedent'sHome
<br />St. Francis Skilled Care � � ���
<br />Bc. CITY OR TOWN OF DEATH pnclude 7Jp Code) 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />ea.�sro�ce-srare sn.�urm Bc.CITYORTOWN
<br />Nebraska Hall Grand Island
<br />8d 3TREETANDNUMBER Be. APT. NO 8f. ZIP CODE 9g.IN31DE CITY LIMRS
<br />3865 South Engleman Road 68803 ❑ YES 7CI No
<br />t0a. MARITAL STATUS ATTIb1E OF DEATH �Martied 0 Never Mertied 10b. NAME OF SPOUSE (Firat, Middle, Lest, 9uHbc) If wife, glve maiden neme.
<br />❑ Married, butseparfltad 0 Widowed ❑ DNorced ❑ Unknown Erika Voigtlaender
<br />11. FATHER'S-NAME (Firet, M�ddle, Laet, Su(fix) 12. MOTHEH'S•NAME (First,
<br />Wilber LeRoy Gannon Eleanor
<br />13. EVER IN U.S. ARMED FORCE87 Dive datea ol aervice il yea. 14a. INFORMANT-NAME
<br />cva 10i12/196 Erika Gannpn
<br />1b. METHOD OF DISPOSITION t ER-SIpNATU • �r�l J�
<br />r� � �BUriel ❑Donatlon � '
<br />QCrematlon ❑ Enlombmenl �• EMETE REMATORY OR LOCATION
<br />❑Remwal ❑OtAer(SpecltyJ Cedarview Cemeterq
<br />17a FUNERAL HOME NAME AND MAILIN� AODRESS (SVeet, Ciry orTown, Stete)
<br />186. LICENSE N0.
<br />CITY / TOWN
<br />Middle, Meiden Surname)
<br />Helea Schultz
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife '
<br />t 6c. DATE (Mo.. Dey, Yr. )
<br />July 25, 2008
<br />STATE
<br />Doniphan, Nebraska '
<br />17b. Zip Code
<br />Apfel Funeral Home 1123 West Second, Gran.d Island, NE. 6$801
<br />1& PAHT 1. Enter the ohefn of eventa»diseasea, injuries, or complicatlona-thet dlrecUy caused the deaUi. DO NOT enter terminel erents auch ae cerdiac arreat, � APPROXIMATE INTERVAL
<br />reapiratory errest, or venhiculer Hbrllledon without ahowing the edology. DO NOT ABBREVIATE. Enter oniy one cause on a Iine. Add additlonel Iines H neceseary. �
<br />INPAEDUITECAUSE: � onaetrodeath
<br />����E,� �a► �►�.sw«\� �.�11 �.�R � �.,��, y ; �3
<br />�°��°���^8 DUETO,ORASACONSEQUENCEOF: I onsetrodeeth
<br />61 d�fll) I
<br />se�,ewauyna�co�uons,n ro> '
<br />enY�leadingtothacausells�i �
<br />DUE T0, OR A9 A CONBE�UENCE OF: i onaetto death
<br />on Uire a.
<br />EM�theUNDQiLYOdaCAU9E �
<br />(dlseasealnJurqthetwtlemd ��1 �
<br />mea�nmreeutttrremae�n) �
<br />� DUE T0, OR A3 A CONSE�UENCE OF: I onset to daath
<br />I
<br />(� �
<br />18. PART II.OTHER SIONIFICANT CONDITIONS-COndffione oontributing to Ne death but not resultfng in Ne underiying ceuse given In PART I. 18. WAS MEDICAL EXAMINER
<br />C ��� OR CORONER CONTACTED?
<br />❑ YES �NO
<br />20.IFPEMALE: 21aMANNEROFDEATH 21b.IFTRANSPORTATIONINJUHY 21c.WASANAUTOP3YPERFORMED7
<br />❑ Not pregnent wflhin past yeer �Naturel ❑ Hom(dde ❑ DrivedOpereror
<br />❑ Pregnant et time ot death ❑ Axident❑ Pending InveadgeUon
<br />❑Paese�er � YE8 �NO
<br />❑ NWpregnaM,butpregnentwithin42tlaysoftleath ❑P ��� 21d.WEHEAUTOPSYF(NDIN�3AV/ULABLETO
<br />❑ SWctde ❑ Could not be defermined ❑ p�her (Spectly)
<br />❑ Not pregnent, bN prepnent 43 daye to 1 year betore death COMPLEI E CAU3E OF DEATH?
<br />❑ Unknown If pregnant w(thin the pest year 0 YES 0 NO
<br />22a. DATE OP INJUHY (Mo., D, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, ferm, etreet, factory, oHice building, construction ette, etc. (3pecity)
<br />N p'C m
<br />?2d.INJURYATWORKT 22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT. N0. CIiYlfOWN
<br />SDUE ZIPCODE
<br />?.3a. DATE OF DEATH (Mo., Dey, Yr � 24a. DATE SI�NED (Mo., Day, Yc)
<br />�� �-i�•- �� �.��
<br />� 23b.DATESiONED (Mo.,Dey�Yr.) 23c.TIMEOFDEATH �� 24c.PRONOUNCEDDEAD (Ma,Dey,Yr.)
<br />��o �1 �3: �O m �o.a�
<br />� �
<br />� 23d. To the bes of my knoxrledg eath oc d the ilme, deie end place ��� 24e. On the basfs af exeminedon and/or im
<br />�� e to th (s) te . na! d TIUe )♦ .� p the tlme, date end plece and due to tl
<br />~ � ~� o
<br />2an.r�� oF o�ni
<br />m
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />infon deeth oxurtetl et
<br />(31grreNre and Tltie ) ♦
<br />25. DIDTOBACCO USECONTRIBUTETOTHE DEATH? 28a. HA3 OROAN OR TISSUE DONATION BEEN CONSIDERED7 28b. WAS CONSENT ORANTED?
<br />ES 0 NO ❑ PROBABLY 0 UNKNOWN �O YES NO Not Applicebie if 28e le NO ❑ YES � NO
<br />27.NAME,TITLEANDADDRESSOFCEHTIFlER (PHYSICIAN,CORONER'SPHYSICIANORCOUNTYATTORNEI� (iypeorPrGrt)
<br />Steven Huaen M.D. 2116 W. Faidleq Ave., Grand Island, NE 68803
<br />28e. REOISTRAR'9 SIGNATURE 28b. DATE FILED BY RE013TRAR (Mo., Oey, Yr.)
<br />�• � ` . JUL 2 9 Z008
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