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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AVE? ,HUMAN SERVICES, IT CERTIFIES
<br />f THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA QF HEALTH AND
<br />' HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VILA A.EcbkDSt _5
<br />DATE OF ISSUANCE
<br />06/21/2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA • DEPARTMENT OF
<br />1. DECEDENTS-NAME (Fist,. Middle, Last Sul0x)
<br />Roy Hochstetler
<br />4. CITY AND STATE OR TERRITORY, OR FORE/ON COUNTRY OF BIRTH
<br />Wood River, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-34 -7368
<br />lib. FACILITY-NAME (If not Inslltution,give street and number)
<br />Wedgewood Care Center
<br />Sc. CITY OR TOWN OF DEATH Maud* ZIP Code(
<br />Grand Island 68803
<br />9d. STREET AND NUMBER
<br />704 S. High Street
<br />106. MARITAL STATUS AT TIME OF DEATH ..RI Marred , ❑ Never MartlW 10b. NAME OF SPOUSE (First Middle, Last, Suffix) N wife, gtva makien nwns.
<br />❑ Marled, but eprated ❑ Widowed: ❑ bloomed 0 Unknown
<br />Last
<br />11. FATHER'S-NAME (Fist,., Middle,
<br />Ezra Hochstetler
<br />13. EVER IN U.B. ARMED FORCES? Give dates of service H Ya. 14a. INFORMANT-NAME
<br />(Yes, No, or Unk.) Yes 09/03/1952 - 09/02/1954 Doris Hochstetler
<br />16a1 EA�AI.rdER31GN/CTI d
<br />I 16d. CEMETENr,CREMATORY OR HER LOCATION
<br />Mt. Pleasant Cemetery
<br />16. METHOD OF DlSPOSmON
<br />®9cnn ❑DOmaon
<br />❑ cxamWbn ❑EotoMnrnt
<br />❑ R.MIVIRMI ❑0t .1Sem y)
<br />17a. FUNERAL HOME NAME AND. MAILING ADDRESS (Street City or Town, Stale)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />11. PART L&ncr U. gram sew- olsssn, or calpllooUOm- that Directly crowd we 40111 DO NOT. Wmibial lMn well as carrot 1040.
<br />n aldwtwy won or wMlkoev ab1geon showing ao etiology DO NOT HATE Ewer only one mow on • 110. 44d add*lowl Oros If n.c+wsry.
<br />CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting a)
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE : OF:
<br />Segue/ 11411y let conditions, if b)
<br />any, : leading to the cause listed
<br />onenea DUE TO, OR ASA CONSEQUENCE OF.
<br />Enter the UNDERLYING CAUSE . c)
<br />(disease Cr YtJvythat Initiated W E TO, OR AS A CONSEQUENCE OF:
<br />the events resulting in death)
<br />LAST
<br />AT WORK?
<br />❑ YES 0 N
<br />236. DATE
<br />J
<br />d)
<br />14t PART S. OTHER SIGNIFICANT CONDn1ONS-Condldans contributing to the dont but not mulling In EM mdadyhq cause p i o n Nt PART L
<br />20. IF FEMALE:
<br />❑Not pregnant within past year
<br />❑Pregn1M at time of death
<br />❑ Not pregnant but pregnant within 42 days of death
<br />❑ 1401 pregnant but pregnant 43 days to 1 yew before death
<br />❑UMmownIf pregnant within the pat year
<br />22a. DATE OF INJURY (Mo., Day,
<br />26a.. REGISTRAR'S SIGNATURE
<br />Yr.)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />226 LOCATION or INJURY - STREET 3: NUMBER APT. NO.
<br />23a. DATE OF DEATH (Mo., Day,. Yr.)
<br />June 13, 2013
<br />(Mo., Day, Yr.)
<br />2013
<br />...PM TOBACCO r ONTRIBUTE TO THE DEA
<br />❑ YES J ❑ PROBABLY ❑ UNK
<br />SuEBX)
<br />22b.11140 Of INJURY
<br />STATE OF NEBRASKA
<br />1 -1.05567
<br />23c. 7114E OF DEATH
<br />4:30
<br />Ss. AOE.Last Birthday
<br />(Yrs.)
<br />81
<br />Doris
<br />21 ER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Cod not be determined
<br />220. PLACE OF INJURY -At home, farm, street factory, ant
<br />cITY,rOWN
<br />am
<br />23d. T • S» Wet .. knowledge, death occunM at the time, date and pace
<br />• tea : ) stata4 (Sian re and TIDe)
<br />Van Winkle
<br />s in
<br />26a HAS ORGAN OR /ISSUE
<br />❑ YES
<br />..
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />John A. Wagoner M.D. 800 N. ALpha Avenue,
<br />HEALTH AND HUMAN SERVICES
<br />2 0 0
<br />,2 tt% 3
<br />v t
<br />O
<br />511. UNDER 1 YEAR
<br />M08. l DAYS
<br />ea. PLACE OF DEATH
<br />M IMI.: ❑ MMMIK
<br />❑' EWOutpapsnt
<br />❑ DOA
<br />9c, CRY OR TOWN
<br />Cairo
<br />1 9s, APT. NO
<br />Middle,
<br />I 12. MOTHER'S -NAME (First,
<br />Sadie Roth
<br />„STANLEY S COOPER 1 ✓ 1
<br />ASSISTAIrSTATE REGIS
<br />`1DEPARhT)*1 4TL PIIEALTH -ANI©
<br />' HUMAN SERVICES `
<br />tea LICENSE
<br />2. SEX
<br />Male
<br />Ss. UNDER 'DAY
<br />HOURS MINS.
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />crTYrrOWN
<br />Cairo
<br />9f. AP CODE
<br />68824
<br />Sib. IF. TRANSPORTATION INJURY
<br />❑ DdveNQpendor
<br />❑ P1118n91f
<br />❑ Pedestrian
<br />❑ other (Specify)
<br />241. DATE SIGNED (Mo.,Dsy. Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />T10N BEEN CONSIDERED?
<br />Grand Island, NE
<br />68803
<br />24672
<br />3. DATE OF DEATH(Mo..DayYr.)
<br />June 13, 2013
<br />IL DATE OF BIRTN (Mo., Day, Yr.)
<br />April 28, 1932
<br />=gal CM Nursing Hon./LTC ❑ Hospice Facelty
<br />❑ Decedent's Home
<br />❑ Other(SPeciM
<br />140. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />140. DATE (Mo., Day, Yr.)
<br />June 17, 2013
<br />APPROXIMATE INTERVAL
<br />:.
<br />onset to death
<br />1 ( w
<br />Part b
<br />onset to death
<br />Ionian edeath
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑. YES 114/NO
<br />21c. WAS AN AUTOPSY
<br />❑ Yea t 1+a
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAIINE OF DEATH?
<br />❑ YES Ditto
<br />tiulidlap, somlructlon INS. eW (Spseih)
<br />STATE ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On at Me Um., date and place and dodo to �*) stated. (Signature : rib)
<br />26b. WAS CONSENT DIMMED?
<br />Not AptIUce W 0 S 211. Is NO ❑ h
<br />28b. DATE PILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUN 19 2013
<br />9g. IHSIDE CRY LIMITS
<br />®Yes 0 N
<br />STATE
<br />Nebraska
<br />17b. Zip Core
<br />68801
<br />m
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