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<br />1. DECEDENTS-NAME (First, UdAI., Last, Suffix)
<br />George Arthur Whitehead
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />3. DATE OF DEATH (MO..Day.Yr.)
<br />October 2, 2012
<br />R DATE OF BIRTH (Mo., Day; Yr.)
<br />November 10, 1924
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF S1RTN
<br />Anoka, Minnesota
<br />6.. AGE -Last Birthday
<br />(Yrs.)
<br />87
<br />6b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />HOURS
<br />INNS.
<br />7. SOCIAL SECURITY NUMBER
<br />476-20-3670 :'.'
<br />ea. PLACE OF owe
<br />IdninALI ® ewet ore 'QTE&D'NW.Wg Herne/LTC ❑ Hoodoo Faddy
<br />❑ EIVOulPeWoot ❑ Decedent'. Item.
<br />❑ DOA ' ❑Dtihr(aP.an)
<br />S. FACLITY- NAME. (if not InstItudon, give Nest and m ter)
<br />Veterans Affairs Medical Center
<br />Sc. CITY OR TOWN of DEATH (Ipolud. VP Cods
<br />Grand Island 68803
<br />Id. COUNTY OF DEATH
<br />Hall
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />56. CRY OR TOWN
<br />Grand Island
<br />9d. STREET ANDNUMBER
<br />1008 East Phoenix
<br />M. APT. NO.
<br />It ZIP CODE
<br />68801,
<br />$g. INSIDE CITY WRITS
<br />® Yes '❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ElMrdsd :❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Untlnorm
<br />106. NAME OF SPOUSE (First, Middle. Last, SWIG) If v/Ifn dot maiden ern..
<br />Lucille Wyman
<br />11. FATHERTNtAME (First, Middle, Lad, Sullix)
<br />Arthur James Whitehead
<br />12. Mermers.NAME What, Middle,,. MYMn Surname
<br />Made Muria! Kiser
<br />13. EVER N U.S. ARMED FORCES? Give dates of service N Y...
<br />(Yee, nor or than.) Yes 03/2711 1964
<br />14. INFORMANT -NAME
<br />Lucille Whitehead
<br />14b. RELATIONSHIP TO DECEDENT ..
<br />::Spouse
<br />15. METHOD OF DISPOSRION
<br />Mau O nntsoea
<br />0e nr.4on wnud
<br />R.I 1 D0ne.0e.4eerM
<br />1 TU
<br />' '
<br />:155. UCENSE t40.
<br />/Z go
<br />ISo. DATE (Moe, Day, Yr.)
<br />Octobers, 2012
<br />. /I
<br />11d. CEMETERY, ' ' OR OILER LOCATION CITYIrOMIN STAT
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MALNG ADDRESS (Street, City or Town, Stab)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Cant
<br />68801
<br />CAUSE OF DEATH (See Instructions and exameles)
<br />1e. PART I Enter an ie15JI L.dOY•dl.nPs,5544...reo.eweetlwf 00 ancdr mama Senn*. 0O110T holey WNW 0011s sunhat argon rent, , APPROXIMATEINT9NAL
<br />.apk ..r ann. o ,n1016ierflbI5Mbn without 00 tie Mangy. DO NOT AIII IVIATE. Orr only one COUP on • Ana. Mn .ddrelat Una if mammy. 1
<br />IMMEDIATE CAUSE: 1 aset to death
<br />IMMEDIATE CAUSE (Final
<br />aamdN{on 01111110110 >a CtltCl ' \ Mk'N ,C∎ �
<br />In
<br />death)
<br />DUE TO, OR AS A CONSEOUENCE onset b death
<br />BnIueMlla I1.t com+Rlal K d > s. 1 T , z): \\ C t \ Q hc '1x
<br />,ny, I..dlrw ro me esrne.leud � t i
<br />h
<br />on Sma. DUE TO, OR As A CONSEQUENCE OF:.': , 011011 to dwell
<br />Enter the UNDERLYING CAUSE C) �� *! 11 sr r ,h `
<br />\l �^l N.A ` w
<br />(disease or injury that initiated `
<br />th Writs read 5th in death) DUE TO, OR AS A CONSEQUENCE OF ::: , onset to death
<br />LA ST
<br />w1 h
<br />TI 1
<br />15. PART 11. OTHER SIGNIFICANT CQA :amMMding tine death but not r..u51ng In tie ind ent* abuse o In PART 1. -..:
<br />� �w,.
<br />QL
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />20. IF FE 1
<br />❑ Not Predu nt0NNn Met yea. ' .
<br />❑Pregnant at time OWE'
<br />❑ Not pragnrd, but pregnant within 42 days of death ::
<br />❑Nor pregnant, but mom* 43 days to 1 year before death
<br />❑Unlutown If arsons* within the Prot Inter
<br />21a. MANNER OF DEATH
<br />❑ Handelde )
<br />❑Accident ❑ foetid,* m weld. lion
<br />❑ suicide 0 Could not a determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Op tor
<br />'❑ Passenger
<br />0 Pedestrian
<br />❑OIMr (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />: ❑ YES Li.^
<br />` FINDINGS
<br />216 W AUTOPSY WERE AUTOPS AVAILABLE
<br />' TO COMPLETE CAUSE OF DEATH?
<br />; ❑ YE.S ❑ NO
<br />22.. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. THE OF INJURY
<br />m
<br />22c. PLACE OF INJURY -A1 hone, farm, street, lean?. oaks bidding. oorstiucdon Nb..lc. (SP•ciy)
<br />22d. INJURY AT WORK?
<br />QYE* 'No
<br />22s. DESCR19E HOW INJURY OCCURRED .. :
<br />22f. LOCATION OF INJURY - STREET 4 NUMBER, APT. NO. : CITYITOWN:; STATE 2aP CODE
<br />1.1 !
<br />a g 0
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CNf` fShQC ©�\ ©(a
<br />< J
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. THE OF DEATH
<br />2 311. DATE SIGNED (MO...Day,Yr•) r
<br />Oc obeC 0 ®
<br />235. TIME OF DEATH
<br />(.o' a
<br />240. PRONOUNCED DEAD (M... Day, Yr.)
<br />241. TOM; PRONOUNCED DEAD
<br />m
<br />,1
<br />s e. data ... end place lu
<br />8 0 to 23d. To tlbbt Pink ! ®, :/ )
<br />o y j o
<br />lond 00a00311n00
<br />245. On me basis of ronanatIon and er portion, In my Opb 1Oh
<br />at tint time, data and place and due b the cauaMs) stated. (Signature and TAI.)
<br />25. DID TO U8E • • y TO THE DEATH? .. HAS ORGAN OR UE DONATION BEEN CONSIDERED?
<br />2
<br />OM ND ❑ PROBABLY 0 UNKNOWN I 0 YES NO
<br />215. WAS CONSENT GRANTED?
<br />Na Applicable N20e NO 0 YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />� ® \ ` ® _ . 1 ® i . ' • .-. ® > i e:Qd Q ,
<br />B ♦
<br />_ a A . ®.1C4, .. 1 ti t
<br />, 2
<br />2aa. - IBTRAR'S SIOf4ATURE:: /
<br />5). DATE PILED BY REGISTRAR (Mo., Day, Yr.)
<br />licT 9 7019
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND'HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA 6 ARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT,J.•RLORDS.
<br />STANLEY COPPER
<br />ASS15rAN STATE RaFISTRAR
<br />DEP4RTME OP,HEALtti AND
<br />HCIM�4N.SER jIC
<br />0
<br />a
<br />0
<br />DATE OF ISSUANCE
<br />10/11/2012
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201301103
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />_w�w�eoe.A:. TO.AC .1C:A.T'LI
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