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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donald LaVeme Suck
<br />2. SEX
<br />Male
<br />-
<br />3. DATE OF DEATH (M0.,Day,Yr.)
<br />October 20, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Phillips, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />82
<br />5b. UNDER 1 YEAR
<br />5a UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />March 18, 1932
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAI. SECURITY NUMBER
<br />506 -38 -6965
<br />8a. PLACE OF DEATH
<br />1Stallffie(.i ® lnPanant QI11E8:0 Nursing Homs<C ❑ Hospice Facility
<br />❑ ERIOutpatlerd ❑ Decedent's Home
<br />❑ DOA ❑olher(sPeeecrr)
<br />86. FACILITY -NAME (K not lnstItudon, give street and number)
<br />Veterans Affairs Medical Center
<br />se. CITY OR TOWN OF DEATH (Include Zip Cods)
<br />Grand Island 68803
<br />8d. COUNT! OF DEATH
<br />Hall
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9e. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2219 N. Howard
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />gi Yea ❑ N
<br />10s. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed 0Divorced ❑Uflknow"
<br />Mb. NAME OF SPOUSE (First, Middle, Last, Suffix) NMI., give maiden name.
<br />Shirley Blanche Burrows
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Henry A Suck
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Minnie Rudolf
<br />13. EVER IN U.S. ARMED FORCES? Give dates of sondes H Yes.
<br />(Yes, No, or Unk) Y: 02115/1 52 -06/1 0.19
<br />14a. INFORMANT -NAME
<br />Shirle Blanche Suck
<br />146. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />Cl ❑
<br />®Cameron ❑Enlombepn
<br />❑ Removal ❑txA.dap.cnyl
<br />18a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />1611. DATE (Mo., Day, Yr.)
<br />October 22, 2014
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17s. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PART L Enter EN Etta aCKaOM - pesases, injuries, weempnutlona• that directly causes the death, DO NOT eatermmeMl ewmre seep es curiae arrest, APPROXIMATE INTERVAL
<br />respiratory pest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE FAIN OW one puss on a ens. Add ecdaleeat laws if necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final j rt
<br />disease or condition resulting a) C. FC f A R c- . C4' Cf ve ,,,,,,A o(- 1(!t AArE jr7Ta M6 (437rr7sC 1 lt "A-SE
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, N b)
<br />any, leading to the cause listed
<br />on lire a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Eider the UNDERLYING CAUSE c)
<br />(disease or injury that initlated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d)
<br />18. PART It OTHER SIGNIFICANT CONDITK)NS-Conditlons cont.lbutlng to the death but not restating In the underlying cause given In PART!.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES IN NO
<br />20. IF FEMALE:
<br />❑ 1401 pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown U pregnant within the past year
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />❑ Accident ❑ Pending investigation
<br />ID Suicide ❑ Could not be determined
<br />216. M TRANSPORTATION INJURY
<br />❑ DrMrlOparstor
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Othar (Sp•eNy)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES II NO
<br />21d. WERE COMPLETE CAUSE O FINDINGS EAT ABLE
<br />TO COMPLETE CAUSE � DEATH?
<br />❑ YES ®NO
<br />22a. DATE OF INJURY (Mo., Day, Vr.)
<br />1 22b. TIME OF INJURY 1
<br />M l
<br />22e. PLACE OF INJURY -At home, farm, street factory, office building, conabvcton site, etc. (SpeeIy)
<br />225. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />1 22e. DESCRIBE HOW INJURY OCCURRED
<br />22E LOCATION OF INJURY • STREET & NUMBER, APT. NO. CITY/TOWN STATE 20P CODE
<br />B' M
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Q be r dC m ..0 1`I
<br />s I
<br />O
<br />pC
<br />tU
<br />$ Z
<br />z t.
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. 1114E OF DEATH
<br />m
<br />230. DATE SIGNED (Mo., Day, Yr.)
<br />A oZ�/ / biL�
<br />23e. TIME OF DEATH
<br />03 0l• A.m
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. To the best of my kn., • s, death occurred at the time, data and place
<br />a . 'r' gnature and T111.)
<br />.. �`� _ if rlt •0
<br />6
<br />24a. On the basis of examination atl/or Invsstlgaden, In my opinion death occurred
<br />at the time, date and plop and due to the eause(a) stated. (8lgnatue end Title)
<br />�C
<br />25. DID TOBACCO USE • 511 BUTE TO THE DEATH7"" - -J
<br />❑ YES NO ❑ PROBABLY ❑ UNKNOWN
<br />fa �
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ® NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable N 281 is NO ❑ VES ®NO
<br />27. NAME, TITLE ANO ADDRESS OF CERTIFIER (Type or Print)
<br />yr►a21� 5aniut,e tt)hcx ,rr.h. VAmC a)Q, N_ [3t, Van Gv�cL 6FJ lvb /scµrvl), NE' ��'803
<br />28a. REGISTRAR'S SIGNATURE
<br />Cftfell
<br />OCT $ 4 2014
<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 NEBRASK t OEP Th1ENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ITAL RECOIROS, '
<br />i
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<br />2.
<br />3
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<br />DATE OF ISSUANCE
<br />10/28/2014
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201407067
<br />STANLEY S..COOPER
<br />ASSIST T STATE REGISTRAR,
<br />DEPAR . T HEALTI AND
<br />H /MAN E VICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES -,
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