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STATE OF NEBRASKA �� � �_� � � � �
<br />W,HEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAt7'1�'�'' D�l�t/�+'IAN �EI�IIICES, IT CERTIFIES
<br />' THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEQR,�SIUI 1�P OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY �'OR fiLiTs9L,RECQl2f�� :,:°
<br />;'
<br />DATE OF ISSUANCE /���� �.' �L�_ "� -' -
<br />04/26/2011 STA1V��'S .�-�'O,�E/� ; : " �;
<br />A�SI.�a.T/1N7''�-�fii�-7'E . �
<br />DEPAV3�MEMT OF HEA�7H �ktVD , < �
<br />LINCOLN� NEBRASKA HUP'JAN'�R�/ CES r��",• r'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ``.t' .����: yi'�� Y
<br />c�QT�Gir_e-r� nG n�eTU `'• �trr� Y� ;. ,� 11 01334
<br />1. DECEDENT'S•NAME (Ftrst, Middle, Last, Suffbc) 2. SD( 3. DATEDRDEATH (Ma., Day, Yr.)
<br />Catherine May Yoss Female `April22, 2011
<br />4. CiTY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►$d MOS. DAYS HOURS NUNS.
<br />Wallace, Nebraska 87 January 25,1924
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />506 os H PITAI. ❑ tr�ane� or � Nwsing Home/1.TC � Hosplce Faell(ty
<br />86. FACILffY-NAME (if not Institutlon, gNe street and m�mbar) � ERlOutpatterR ❑ Decederrt's Home
<br />�
<br />� Wedgewood Care Center ❑ ooA ❑ Other(Sp�iiy)
<br />� Bc. CITY OR TpWN OF DEATH p�rclude 21p Code) Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 8a. RESIDENCE-STATE 8b. COUNTY 9c. CITY OR TOVYN
<br />Z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER 8e. APT. NO. 8�. ZIP CODE 8g. INSIDE CITY LIMITS
<br />� 3112n E Seedling Mfle 68801 � vES ❑ No
<br />' 10a. MARRAL STATUS AT TIME OF DEATH Q MarHed ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, I.ast, Sufflx) H wife, gtve maiden �me
<br />� ❑ nneMaa, b�n ��c�a p wnaowea ❑ owo.cea ❑ u�ow� Harold voss
<br />�
<br />m
<br />� 11. FATHER'S-NAME (First, Mlddle, Last, Sufflu) 12. MOTHER'S•NAME (Firat, Mlddle, Malden Sumame)
<br />� Carl A Ba►tenbach Sarah Alice Pittenger
<br />°- 13. EVER IN US. ARMED FORCES? Glve dates of servlee If Yea. 14a. INFORNL4WT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ nes, No, or unk.> No Michael J Voss Son
<br />,� 75. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ Burial ❑ Do�tlon
<br />Kevin Wood 1325 April 26, 2011
<br />� CremaUOn 0 Errtombment �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (SP��Y)
<br />WesUawn Memorial Park Crematory Grand Island Nebraska
<br />1Ta. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cily or Town, State) 17b. Zlp Code
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />CAUSE F DEATH See Instructions and exam les
<br />1Bi PART L Fsterthe chetn of evaMe.4l�s, In1�ulea, or eomplieadon�that GUepiy ceueed ths deatl�. GO NOT e�Rer terminal eve�rts sueh ae wMlae erteat, C APPROXIMATE INTERVAL
<br />resplretary anesf, or ve�rtriwtar flbrlliaBOn wkhout ehowin8 �e et1c1c8Y. DO NOT ABBREVWTE. EMer onty one eause on a 16re. Add addRlonal 14rea H �reeeasary.
<br />IMMEDIATE CAUSE ; ormet to death
<br />mm�eEOwre cause tFl� a) Congestive Heart Failure ; 6 Months
<br />dlaease or conatuon reaumng
<br />��� DUE TO, OR AS A CONSEQUENCE OF: ' o�qet to death
<br />saw��h �� ��mno�, n b) Diffuse Vascuiar Disease � Chronic
<br />emr. ieaamg u me cause nscea
<br />on Nre a DUE TO, OR AS A CONSEQUENCE OF: 7 onaet to death
<br />Enmr sne unm�rwo cause �)
<br />(1�leea96 of Injury ttmt Infdated
<br />the eveMe resuieng in death) DUE TO, OR AS A CONSEQUENCE OF: 7 o�et to death
<br />� d)
<br />18. PART n. OTHER SiGNIFlCANT CONDITIONS�omlftiorre eoMHbuting to the death but �rot resulUng In the undertyi� cause gtven In PART I. 79. WAS MEDICAL E7(AMINER
<br />RestricWe Alrvvay Disease OR CORONER CONTACTEDT
<br />� o,� � No
<br />W O. IF FEMALE: 21a. MANNER OF DEATH 216. IF TRANSPORTATION INJU 21c. W/6S AN AUTOPSY PERFORMED7
<br />LL
<br />� � Not pregna�rt wlthin past year � Natural � Homldtle � DNvedOperator
<br />v � r��n�sn�ma�, � awa�s � Pentlin9lmastiBaHon ❑ P�"ee� ��s � No
<br />'� � Not pre¢�aeR but Pree� wttu�n 42 days ot deatb ��p� �utd not be uetermhred ��e��" 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� Not P�ee�, but P�Bnant 49 daye to 1 Y�' betore death � � � othar lSPeeihl TO COMPLETE CAUSE OF DEATH4
<br />� �] Unlmown H pregna�rt wkh6� Me P� Y�' ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo.. Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF WJURY-At home, farm, street, factory, offlee butidi�, w�truction sfte, etc. (SpeefTy)
<br />�
<br />� 2Zd. INJURY AT WORK? 2Ze. DESCRIBE HOW INJURY OCCURRED
<br />1�-
<br />❑ ves ❑ No
<br />22L LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITYlfOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIM1IIE OF DEATH
<br />.� � April 22, 2011 ,� � �
<br />� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.J 24d. TIME PRONOUNCED DEAD
<br />E v Z A ril 22, 2011 08:35 AM �' � a a
<br />$� o . ro tne eest or my �owteaee. aeam occu�ea ae ene eme. aem ena P�aee $
<br />p 24e.On the baele Mexaminetlon anWOr Imeatigetlon, In my opinlon death occumd at
<br />F 8 ana aue m ure cm�e(s) smma. �s�e�ue ana rme� 8 z� ma nme Aate and ptace and due to tlre nuse(s) steted. (Slgnature and Titie)
<br />� Richard Fruehling, MD � o
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS OROAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNIaIOWN ❑ YES � NO Not Applicable H 28a Is NO ❑ YES ❑ NO
<br />2. TIT ADDRE F ERTIFIER PHYSI IAN, YSICIAN IST , ORONER S P SICIAN OR N A ORNEI� ype or PriM)
<br />Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE � `-,�- 28b. DATE FlLED BY REGISTRAR (MO., Day, Yr.)
<br />' �,� April 25, 2011
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