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STATE OF NEBR�4SKA
<br />WHEN TF`lIS COPY CARR/ES THE RA/SED SEAL OF TME NEBRASKA HF"1iLTH
<br />�YSTEM, IT CERTIFIES THE B�LOW TO BE A TRUE COPY OF THE ORIGINAL-
<br />THE NEBRASKA HEALTH ANb HUMAN SERVICES SYSTEM, VITAL STA'Y�
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />DATE OF ISSUANCE � ` �G��
<br />� Nov o s �oo� � 2 012 0 3 91 G, a��
<br />LINCOLN, NEBRASKA _ ,_ M�A��fl�;
<br />�
<br />STATE OF NEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES FINANC��N9
<br />CERTIFICATE OF D�ATH ,
<br />1. DECEDENT'3-NAME (Firet, Mlddle, Leat, SWtlx) 2..§6X '
<br />Edmund �ames Sonder aard Male
<br />4. CI1Y AND 8TATE OR TERRITORY, OR FOREION COUNTRY OF B�RTH 6a. AOE-Laet Blrthday 6b. UNDER 1 YEAR 6c. UNDER 1 DAY
<br />Grand Island, Nebraska g�re.� MOS. DAY9 HOURS MINS.
<br />7. SOCIAL BECURIT/ NUMBER
<br />507-66-0875
<br />Bb. FACILITY-NAME (If not Inatltutlon, g(ve etreet end number)
<br />VA Medical Center
<br />Bc. CI'fY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68105
<br />9a RESIDENCES'fATE 8b. COUNiY
<br />Bd.STREETANDNUMBER
<br />�� '
<br />�SaNr�r
<br />�! . y � _ l7lfilTl .1a7 i i . .
<br />"� 0 = �
<br />� � �k
<br />� , � n/ � ,�}� �1r;
<br />C i
<br />�G'����!'FtlI7 � d . d' . ..
<br />�'�E'RV/�ES
<br />°� _-
<br />- ;��
<br />-r = �" �'a , TM" �
<br />,
<br />�'����. � ��3�6�35
<br />�.+� 3,OATEOFDEATH'(Mo.,Day,Yr.) I
<br />B. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 2, 1950
<br />N08PITAL: �l Inpaileni 4� ❑ Nursing HomeILTC ❑ Hoeptce Facilfty
<br />❑ ER/OU1pe8eM ❑ DecedeM's Home
<br />❑ 004 CI ou,er es,,edry
<br />ea, courrn oF oean+ '
<br />Douglas
<br />Bo.CITYORTOWN
<br />Be. APT. NO 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />fiRS2(11 � YE3 ❑ NO
<br />10a. MAHITAL STATU3 AT TIME OF DEATH $) Marrfed ❑ Never Married 10b. NAME OF 9POUBE (Firat, Middle, Leat, SutlbcJ N wife, glve meiden name. �
<br />❑ Merried, but aeparatad ❑ Widowed ❑ Divoroed ❑ Unkrrown
<br />Jean. Tkl�nmas
<br />11. FATHER'S•NAME (Firet, Mlddle, Lael, Sutllx) 12. MOTHEH'S-NAME (Firel, Mitldle, Melden Surname)
<br />� Edmund p. Sonder aard Lillian Hansen
<br />13. EVER IN U.S. ARMED FORCES7 Qhe dates a( service if yea. 14a.INFORMANT NAME 14b. RELATION3HIP 70 DECEDENT
<br />i��,�o,o���k.� 4/10/68 - 4/9/71 Mary Jean Sondergaard wife
<br />15. METHOD OF DISPOSITION t6a. EMBALMERSIONATURE 18b. LfCENSE N0. i 6c. DATE (Mo., Day, Yr. )
<br />�e��, ❑oo��ro� �� 1326 Oct. �_ 2T, 2006
<br />❑Crematlon ❑Entombment 18d.CEMETERY,CREMATORYOHOTHERLOCATION C�TY/TOWN 3TATE
<br />❑Removel ❑Other(SpecHy) Westlawn Memorial Park Grand Island Nebraska
<br />17a FUNERAL HOME NAME AND MAILIN� ADDRE99 (Sheet, City orTown, 8fate) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust St.,Grand Island,NE 68801
<br />18. PART I. Enler the chaln of events--diseasea, inJurlea, or complicaUans-•that directly oauaed the death. DO NOT enter terminel eventa euch as cerdlea arreal, � a'P�XIMATE INTERVAL
<br />reaplretory arreel, m venVi¢uler fibriilation withoul ahowing the ellology. DO NOT ABBREVIATE. Enter anty one cauee on a Iine. Add addidonel Mes R necessery. �
<br />IMMEDU�TE CAUSE � anset to death
<br />m�,�ou,�cause��� ��� Mul ti system organ fai 1 ure � 1 week
<br />��� DUETO,ORASACONBE�UENCEOF: " I onaettodeath
<br />In deaUf) �
<br />SequentlellylletcondlUm�s,H ro� Sepsis, end-stage renal dmsease ; month
<br />���� DUETO,ORABACONBE�UENCEOF: I onaettodeath
<br />on Ilrre a.
<br />I
<br />Fster9m UPIDERI.YINO CAUSE
<br />(disea�orinJurythetlnWated ��� Thrombocvtopenia ; week
<br />������� DUETO,ORASACONSE�UENCEOF: I onaetmdeath
<br />U141' �
<br />(� �
<br />18. PART �I.OTHER SI�NIFICANT CONDI770NS-CondlUone contrlbuting to the death bul not reaulting in the underlying ceuse given in PART I. 18. WA9 MEDICAL EXAMINER
<br />OR CORONER Y CONTACTED?
<br />❑ YE9 �1 NO
<br />20.IFFEMALE: . 21e.MANNEROFOEATH 21b.IFTRANSPORTATIDNINJURY 21o.WA3ANAUTOPBYPERFORMED7
<br />❑ Not pregnanl within pasf year • � Netural ❑ Homicide ❑ �rNedOperator�
<br />❑ Pregnent et time ot dealh ❑ Acoident0 Pending Imesligetion
<br />❑Passenger � YE5 �l NO
<br />❑ Not prepnanl, but pregnent wlthln 42 days ot death � P ���
<br />❑ Sulnide ❑ GoWd not 6e determined � a�r (Bpecfty)
<br />❑ Notprepnenl,butpragneM43deystolyearbetaredeath
<br />❑ Unknown N pregnent wllhin the pasl year
<br />22a. DATE 9F fP1JURY (iv1o. -0oy, YrJ --- 22t:"fR71E OF INJI3RY - 2^<5. PLACE 6F INJUAI'-At noma (arm, straei,-taciory, oiike
<br />m
<br />22d.INJURYATWORK? 22e.DESCRIBEHOWINJURYOCCURRED
<br />[] YE9 ❑ NO
<br />22t. LOCATION OF INJURY � STREET & NUMBER, APT. N0. (�iYIfOVJN
<br />21d. WEREAUTOPSY FINDINCi3AVAILABLETO
<br />COMPLETE CAUSE OF DEATH7
<br />❑ YES ❑ NO
<br />trucifon eTte; etc. (Spec�y) -"- -'
<br />ST1UE ZIPCODE
<br />23e. DATE QF DEATH (Mo., Day, Yr.) 24a. DATE 91�NED (Mo., Day, Yr.) 246.TIME OF DEATH
<br />�� October 23 2006 .�� � "'
<br />� 23b. DATE 816NED (Mo., Day, Yr.) 23c.TIM D ��� 24c. PRONOUNCED DEAD (Mo., Dey,Yc) 24d.TIME PpONOUNCEDDEAD
<br />�
<br />�� o October 25, 2006 �� ��� a m $�� o m
<br />� 23d. T the beat of my knowledge, death occurted et ihe dme, date end plece �� 24e. On the basls o1 exemMallon and/or Investlgatlon, In my opinlon deaih occurred el
<br />�� d u e t o t u a e( a j a t e t e d. ( 6 l g n a l u re a n d T l l l e )� .� p� i h e t i m e, d a t e a n d p l e c e a n d d u e t o t h e c auae(s) stated. (Si g � reture end Title )�
<br />. �
<br />$`o
<br />25. DIDTOBA E MRIBUTETOTHE DEATH? 28a. HA8 ORl�AN OR TISSUE DONATION BEEN CON3IDERED? 28b. WA6 CON3ENT ORANTED7
<br />❑ YES NO ❑ PR09ABLY x7 UNKNOWN � YES ❑ NO Not Appilceble I( 28e le NO O YES �] NO
<br />27.NAME,TITLEANDADDRE330FCERTIFIER (PHYSICUW,CORONER'&PHYSICIANORCOUNTYATTORNEI� (rypeorPdMJ
<br />Venkata Andukuri, M.D., yA Medical Ce,�ter 4101 Woolwvrth Avenue, Omaha, NE 68105
<br />28a.REaISTRAR'SSIONATURE J � , I ��i�•„/_ _ _ _ I 28b.DATEFILEDBYpT'S� O(MZOUOr)
<br />W � R/l� (��•
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