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WHEN THfS. COPYCARR�S THE RA/SED SEAL OF THE NEBRASW4 FIEAL.7H,/iWD HUMANS�'R'V/CES
<br />SYSTI,�Y� iT CFRT/RES THE BELOW TO BE A TRUE COPY OF THE OR/Qll � REG�1?Q
<br />THE AIEBRASKA HEALTH AND HUMAN SERV/CFS SYSTEIY� Vl7'Al„�fiTA7,'78T/���TIFfAi��US`��S
<br />T�f� LEOAL DEPOSfIORY FOR V1TA1 RECORDS , �»�,, � =
<br />DATE OF/33UANCE ;� _ _ � ��'
<br />NOV �. 6 200� � 0 � 2 0 8 6 3 3 _�,�:�� ,;,
<br />� �� . as,s��� ��� � ''��
<br />uacou� aee+aasrca r�rurH A� Hu�K��tc�'s ��� �':'„
<br />_ �� � , � ��� �
<br />7-- �� _ ,�,
<br />STA1E OF ATEBRASKA- DEPAR.IMENf OF HEAL'1'f� AND HUMA� SEK�,�F�� SfkP''POR7" `, �,
<br />VTI'AL STA'f[STICS -- -- -= -�4 . � L '
<br />CERTIFICATE OF D�ATH � -`'= -` � � ;' �; �''
<br />OECEDENT.NAMEVarOyd ...� ��FWST ���.. van MIDDLE -.. *'OSS T 2 sE�^�� 3 Novem � �� 'f, �`�.,
<br />FJ� H '/MpnN -0aV �Y
<br />ii 1z y i�in 'ber 13 2000
<br />:. CiTY ANb STATE OF BiRTH � �mrto! in USA_ name comRry! Sa. AGE - Last BIN�day UNDER 1 YEAR UNDER i DAY .� $..OATE 6F BIRIH� �, IMOnIl1, Oaµ YearJ
<br />Grand Is Ne braska �'"'g' g� � Mos oa�s Sc HOURS ��NS' December 29, 1912
<br />��. SOCIALSECURTIY 8a_ PLACEOF�EATH
<br />5 O C ���� r�, ` HOSPITAL � Inpalient OTHER' � Nurs�ng Home
<br />J 1 �F -
<br />�-.__- _ _ . - _ ___... .
<br />_.�FACILITY�Name (IlnOtmstllulion.givBSfICB1aMnLm6BlJ � E�OuIPe�e�1 RBSid¢ue
<br />Wedgewo C are Center � D0A � °t �`��""'
<br />�CITY. TOWN OR LOCATION OF OEATN � � - 8tl. UJSIDE CIN LIAWTS Be. CAUNTY OF DEAiH
<br />Grand Island Y� � N� ❑ Hall
<br />3=. RESIDENCE - 5TATE �� � Bb COUNTY 9c. CITY, TOWN OR L6CATION � 8d. SiREET AND NUMBER lh�tfudingZ/pCo�l8801 9e. 4NSIDE GTY UAAiTS �
<br />N ebraska Hall Grand Island 3112 E. Seedling Mile Y� 0 No ❑
<br />I0. W+CE - le.g., Whue. Black. nmerican Uuiian. 11. ANCESTRY le.g.��a�n/�rt�s�, etcl 12. � MARpIEO ❑ v✓iDOWED 73. NAME OF SPOUSE NI wda grve maiden neme)
<br />8"��s�`�, White ` r �"E� o��oa�EO Catherine Bartenbach
<br />14a. USUAL OCCUPF7ION lGrve kmd ol work donedu�d,g�mosl tdb. KWD OF BUSINESS �NDUSTRY t 5 EDItCATION (Specily oNy Mghest gtade compleledl
<br />o/ wo,lnnq �ire, even nren.eo� �
<br />$heet M Wor Metal Fabrication �t�t a"�Grac�"e10�t21 �".�or5•�
<br />i6. FATHER-NAME � FIRS7 - MIDQLE ��- � LAST � 17 MOTHEH FIRST hpDOLE MAIDENSUHNAME
<br />Emil J. Voss Christine Mohr
<br />18. wAS DECEASED EVER IN U-S. ARMED FORCES? 19a. INFORMANT • NAME �
<br />IYes. nQ�OuNC.) � flt yes g�ve war and tlatBS ot BBrvlce8)
<br />1V Catherine Voss
<br />�18b INFORMANT MAILINO ADDAE9S (STREET OR R:F.O NO.. GTY OR TOWtd. STATE ZIP�
<br />3112 E. S Mi Grand Island, Nebraska 68801 -
<br />20 EMBALMEH - SIGNATURE 8 LICENSE NO. 21a. METHOD QF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY � NAME
<br />Not Embalmed ��,,;�, ��,�„a� Nov. 14, 2000 Central Ne. Cremation Serv.
<br />22a. FUNEFAL HOME � NAME 21tl. CEMETERY OR CREMATORV IOCATION CITY OR TOWN STATE
<br />Li ston-Sondermann F.H. ��°" ❑°on"�" Gibbon, Nebraska
<br />22b. �FUNERAL HOME ADDRESS . �STRE€T OR RF.D. NO.. CRV �t TOWN. STATE. ZIP)
<br />501 N. Webb Road, Grand Island, Nebraska 68803-4050
<br />23. IMMEDIATE CAU E - (ENTER ONLY ONE C USE PER UNE FOR 181. ib�. AN (CIl� �:. � i ��tenat batween onsei dnd tleam
<br />�r� �� 7 G�i U)c;� l r`vt v�2F�� � r��S�" - N c�f �' ��, �°� � 1 z: /Gc.��� �� SCcG�� �v , G� ��
<br />DUE T0. OR AS A CON�OUENCE OF: . � Interval I�eNrgen onset antl deatn �
<br />�
<br />I
<br />Ibl I _
<br />OUE TO.AR AS A CON5EOUENCE OF• � i trrterval belween onsel antl aeam
<br />i
<br />i
<br />(c! �
<br />-_
<br />- OTHER SIGNIFICANT CONDITIONS - CandUorrs��eorWtb�ng to tlre tleath but rWl relaled � PART UI 1f FEAAALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFEARED TO MEDICAL
<br />P?RT PREGNANCY�IN THE PAST 3 MONTHS? ;,,.i EXAMINER OF CORON �
<br />(Ages 10-94� Yes No 'les NO Ves No
<br />. _-_ . _._ -- _.__.._ . _ . _ _ __. ._ .. _-__ . ..
<br />26a 266. DATE OF pV,IURY �Ma Day. Yr.� 28c. HOUfl OF INJURY 2Bd. DESCRIBE HOW I WURY OCCURREO
<br />� Acc�d@M � Untletermrtretl M
<br />�J Su�cide � Pend+ng 28e: INJURY AT WORK 261. PLAe E OF� O U�RY -�. larm sveec IactOry 28g. l0(:ATION STREE7 OR R.F.D. NO. CITY OR TOWN STATE
<br />� ❑ � OIfiC blAidi
<br />� HOmiCid6 Investiga00n Yea No
<br />�27a. DATE OF DEATH %MO.
<br />. Day. Y�./ 28a. DATE S16NE0 /Mo. Day r,.l �28b. nME OF OEA'TH
<br />$ � 1( / �� C5� �. �
<br />�� 27b. DATE SIGNEA (MO. Day. Y�l 27a ittdEOF OFATH � � �� 28e. PRONOUNCEO DEAD IMo.. Day. Yr.J 2�. PRONDUNCED OEAD fNOenl
<br />4 � ��/rN/�� X : 5p � .: M � `� �
<br />�� 27tl. 7o the best d rtry turow ealh oau+retl at pie Bme. 28e. On the hasis N aMamination aiM�w inveatiga[ron. in my opimon Ceath acurred at
<br />' useis� stat�. L � 2 ���' � g tne cme, mte arw place a�m aue ro ure causels) emtetl.
<br />- Is�qnewre_ana rmel ► ' ._ _ S� aiM rmel
<br />29. �ID TOBACCO USE CpNTRi UTE TO THE DEATH9 - 30.8 HAS OROAN OR TISSUE DONATION BE CONSIpEREO? 30.D WAS CONSENT 6RANTED?
<br />� � VES NO � UNKNOWN � � YES NO � YES �NO
<br />� --- - � - � �
<br />_ --- -
<br />-- - __
<br />31. �NAME AND ADDRESS 6F CEFTIFIEA� (PHYSICbW, CORONEA'S PHVSICIAN OR COUNTY ATTORNEVI ITypea Pfin7
<br />y(1�81 � �.. f�lt l.z� : � C tt �t`, �� �-� � (3(.) �V � �'.
<br />32a REGISTRAR . _.. ___. - . _--.-. ___- _ _..-_- ___ . _'. _.. . � 32b DATEFILEDBV EGISTRAR (MO..DaRYcJ
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