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<br />STATE OF NEBRASKA `��'�,�����,;-;
<br />WHEN TH1S COPY CARRIES THE RA/SED SEAL OF THE NEBRASKA HEALTH /�I`Y,�]V�A�il� S f�CES
<br />SY3T�'M, IT CER'tlFIES THB BELOW TO BE A TRUE COP1' OF TH6 ORIC�?INRI L�'!� A'OAI,�p,F YI(d�
<br />THE NEBRASKA HEALTHAND HUMAN SERVICES SYSTEM, VITAL STAT!$�1��,��l�f�W�H'�S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS, f '° � b �' �
<br />� era ,
<br />DATE OF ISSUANCE , c+ '�.;,,_ � "v °-��? ' '
<br />I�PR 2 � ��� . e �,��Ers-`cooi��
<br />AS�lSTANT STATE REG/ST�3A1�
<br />LINCOLN� NEBRASKA HEA�TH�'�llQ�ltlA�I�..r'�RI�I,��S� r 'a '
<br />-- , 201205549 �:����a6 ` �� w` �,
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<br />s iwi e ur rotnttqsicq-DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO
<br />CERTIFICATE OF DEATH
<br />���, 1. DECEpENT'3-NAME (Firat, Middle, Last, SuHix) 2.SE% 3.DATEOFDEATH (Mo.,Dey,Yc)
<br />4 { f Michael Samuel Sorahan Male Se t. 12 2007
<br />'_�'� °. 4.CITY AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH 6a. AQE•Lflet 8irthday bb. UNDER 1 YEAR 6c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Dey, Yr.)
<br />� Concord, California �r�e.� 65 M09. DAYS NouAS M�NS. Jan. 25, 1942
<br />��..,;:
<br />� 7.&OCULLSECUHITYNUIdBEp � - Be.PLACEOFDEATFI
<br />a r", 5 0 6- 5 0- 0 9 9 0 o 3PITAL � Inpatient �1 ❑ Nursing HomelLTC ❑ Hoapke Facllity
<br />';'�;? `$i Bb. FACIUTY NAME pf not inetltutlon, give atreet and number) ❑ ERJOutpatient ❑ DecedeM�sHOme
<br />�Saint F.�ancis Medical Center
<br />1� ❑ ooa ❑ ou
<br />"��`' ( v ) ea.cout�rroFOearH
<br />,.;�� Bc. CITY OR TOWN OF DEATH Inclutle ZI Code
<br />' Grarid Island 6$803 Hall
<br />,,
<br />�- BaRE91DENCE3TATE Bb.WUNTY Bc.C11Y0RTOWN � � �
<br />� � Nebraska Hall Grand Island
<br />j 9d.9THEETANUNUMBER - Be.APT.NO Bt.DPCODE . Bg.INSIDE0ITYLIMRS
<br />��'� 4.=k 540 E. 11th St. 68801 �res o No
<br />r t0a MAHITAL STATUB AT TIh1E OF DEATH � Marrled ❑ Never dterrled 106. NAEAE OF SPOUSE (Flrat, INtddle; Lest, SuHdc) If wite, give melden neme.
<br />I ��. � ❑Married,butseparetetl OWidowed oo� ❑u��� � Kathlienne �I'08S
<br />�. ;
<br />��'' 11. FATHER'3•NAb/E (Flrat, Middle, Leat, 8uffix) 12. MOTHER'S-NAME (FIYSt, Middle, Maiden 9urneme)
<br />���wa � � Thomas � Sorahan Lila Wald
<br />�� 73.EVERINU.9.ARMEDFORCE3161vedatesofserviceM ea. 14a,MFORMANTNAME idb.RELATIONSHIPTODECEDENT
<br />m �,>. Y
<br />:�; �r�,�o .orunk.) No Rathlienne Sorahan wife
<br />�^.; 15.ME7HODOFOISP03RION 18a.EMBALMER-SIpNATURE 18b.UCENSENO. 18c.DATE (Mo.,OagYr.)
<br />�d� r"� ❑ Buriel ❑ Donedon
<br />�., Not Embalmed '
<br />�4 � gI Cremedon ❑ Entomhment 18d. CEMETERY, CREMATORY 0R OTHER LOCATION CITY / TOWN STATE
<br />fi� ;��! ❑A�� ❑oma,cs�> Central Nebraska Cremation Service, Gibbon, Nebraska
<br />�� �,��°
<br />�`K°; fla FUNERAL HOME NAME AND MAlIJNO ADDRES9 (St�eet, City orTown, Sietej � 17b. ZI Code
<br />f ,�;,All Faiths Funeral Home, 2929 S. Locust St.,Grand Island, NE 6�801
<br />�,�', d i..5� ��.;�','�i', ..�r*m ��� '.��r�,X.�'���... 9 ��tl ��QQ5:G,0K11�,�....Mr"'$ « t ,.� ..Rt %lS "`.e�.�r
<br />Zfi� 1& PART I. Enterthe ohain bi ereMe-diseases, Injurles, or compOcador�e-thet direcUy ceusetl the death.00 N0T eMer termh�al erente euch es cardiec arreat, ' �P��� ���
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<br />,'�`�,�� raspiratory erteat, ar vaMriculer flbrltletion without ahowing the edology. DO NOTABBREVIATE. Enter oniy one cause an e tlne. Add eddidonel Mee fl necessery. i
<br />�; �
<br />.��, :'�: NGMEDWTECAUSE ' � onsetMdeaN
<br />� I
<br />�`�;,`��,, m�o�arecnuse� (al (�(�c.°�-1,�)� brrW.l (.�- c.a+ru.e�' � �� �AAw�I
<br />-" �m�°�� �1�8 DUE T0, OH AS A CONBEOUENCE OF: � a�� �p d�
<br />."'�'�. Ndeffih)
<br />„' M.:
<br />�
<br />In a.
<br />�; SaquantlallyDetcondHlon&N ro �
<br />���`� �Y��9lotheea�me�8t9d �
<br />�,`: ��� OUETO,ORASACONSE�UENCEOF: � p�gg�tpdgq�ry
<br />"� !-
<br />� Erda9leUPIDERLYMOCAUSE I
<br />��� �� (maeaseminJurythatinitletad �°� �
<br />� ` �����^�) DUETO,ORASACONBE�UENCEOF:
<br />��; � , � � � � i onsettodeaih
<br />� r I
<br />' (� I
<br />��' 18. PART II.OTHER SIQNIFICANT CONDRION9-Conditlona comributl� W the death but not resuitlng in the undedying oeuse glven in PAPT I. 18. WAS MEDICAL EXAMINER
<br />�;�s
<br />���� OR CORONER CONTACTED?
<br />c�v° rq
<br />j�"� ��=� O YE8 NO
<br />�'��;g 20.IFFEMALE: 21aMANNEROFDEATH 276.IFTRAN3PORTATIONINJUHY 27aWASANAUTOP3VPERFOHMED7
<br />�`� � 0 Not pregnant wlihin peat year W�Netutei ❑ Homidde ����Ye<<��0� ❑ YES �NO
<br />��� ��: ❑ Pregnant at tlme af death ❑ Accident0 Rending ImeaUgatlon � P �� g � �
<br />,,� ❑ Not pregnant, but prepnent within 42 days of death � P ��� a " 21d WEHEAUTOPSY fWDiN63AVAILABLETO
<br />1� ❑ 8ul¢ide ❑ Could nol be determMed
<br />r p, ❑NOtpreprrem,butprepnent43tleyetofyearbeforedeath ❑Other(Specify)
<br />re COMPLETECAU3EOF�EATH9
<br />_ ❑ Unknown H pregnenl wlthin the pest year ❑ YES fd[ NO
<br />"°�' 22a. DATE OF INJUHY (Mo., Dey, Yr.) 22b. 77ME OF INJURY 22e. PLACE OF INJURY-A1 home, tarm, etreet, facto oHlce bulldin wnetructlon alta, eta (Speciry]
<br />'��3< ry, g,
<br />�.. �
<br />� -��� - - en.. - --- � -- -- -� ----- -- - --
<br />,�,,; -.-- - - �-----�-- --_._. .-�- -- .. . �
<br />��,+.�, 22d.IWURYATWORK? 22e.DESCRIBEHOWINJURYOCCURRED �
<br />z� �:
<br />`� i ❑ YES ❑ NO
<br />r y��� 22f.LOCATIONOFINJURY•3TREET&NUMBER,API:NO. CftY/fOVYN 3WE ZIPCODE
<br />`�4
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<br />;�F 23a.DATEOFDEATH (Mo.,Day,Yr.) 24a.UATE816NED (Ma,Dey,YC) 24b.TItdEOFDEATH
<br />��� ��'� er 12 2007 �'�� m
<br />�� �
<br />�� �� 23b.�ATE3I�NED(Mo.,Day,Yr.) � 23c.TIMEOFDEATH ��� 24c.pRONOUNCEDDEAD(Mo.,Day,YrJ 24d.TiMEPRONOUNCEDDFAO
<br />�;�=�4 �� -(t-��1' 07:30 a. m m`� m
<br />�>�; �� 23d.To the beet of rtry knowledge, deeth axurred et the iime, date ertd place u� �� 24e.On the basis of e�mmination end/or Inveetigetlon. In my opinion daaih oxurted et
<br />N '�"�i � and due ta the cause(s) etated. (Signamre and TfGa )♦ .� � the tlme, date end place and due to the ceuse(e) atated. (Signaiure end Tltie )♦
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<br />r �ir �-�1C �w.. t+�l rl ��� � Pi g
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<br />"�s 25.DIDTOBACCOUSECANTRIBUTETOTHEDEATH? 28a.HA80RQANORTI35UEDONATIONBEENCON3IDERED7 28b.WASCONSENTCiRANTED?
<br />�;
<br />t6 '.'
<br />r���' YES 0 NO ❑ PROBABLY ❑ UNKNOWN , ❑ YES
<br />ti �.# ,�NO Not Applicable ii 28e la NO ❑ YE8 � NO
<br />�j,: 27.NAME,TIttEANDADDRES90FCERTIFlER (PHYSICUW,CORONER'SPHYSICIANORCOUNiYATTORNEI� (rypeorPrlM) �
<br />=�?i�'Anne K. Morse, 729 N. Custer Ave.,Grand Island, Nebraska 68803
<br />' 28a.RE�I3TRAR'S910NATURE 286. DATE FILED BY REQI9TRAH (Ma, Day,Yr.)
<br />. ,�. SEP 14 2007
<br />HHS-81 11/03 f55061)
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