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To be completedlverified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Martin Charles Vodehnal 2. SEX ,, Male t � OFVEAt b., :Day, Yr.) DATE ( . , April` - 5; 91 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ord, Nebraska 5a. AGE - Last Birthday (Yrs.) 84 5b. UNDER 1 YEAR 5c. UNDER 1 DAY. 6. DATE f5F BIRTH (Mo., Day, Yr.) October 8, 1928 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -30 -3486 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Grand Island Veterans Home ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1212 West 9th 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Joan McKay 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Vodehnal 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Frances Ptacnik 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 11/08/1950- 10/30/1952 14a. INFORMANT -NAME Joan Vodehnal 141). RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) April 8, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Hours respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Multi System Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b)Aspiration Pneumonia Days any, leading to the cause listed line on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Right Hip Fracture Days (disease or Injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the drat` ` • not resulting in the underlying cause given in PART I. Alzheimers Dementia; History Colon CA; Ulcerative Colitis; Chronic Lymphocytic Leukemia, CKD 2; History Of MRSA Of Wound /2012. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ❑ Natural ❑ Homicide ® Accident ❑ Pent Investigation ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) March 27, 2013 22b. TIME OF INJURY 07:20 PM 22c. PLACE OF INJURY -At home, Grand Island Vetearns Home farm, street, factory, office building, 22d. INJURY AT WORK? DYES ®NO 22e. DESCRIBE HOW INJURY OCCURRED Fall 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 2300 West Capital Avenue, Grand Island Nebraska 68803 I, w I >. E u z - ' 23a. DATE OF DEATH (Mo., Day, Yr.) April 5, 2013 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 2313. DATE SIGNED (Mo., Day, Yr.) April 8, 2013 23c. TIME OF DEATH 09:00 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD g u O 3d. To the best of my knowledge, death occurred at the time, date and place 5 and due to the causes) stated. (Signature and Title) 2 Jennifer M. Axt, APRN 24e. On the basis of examination and /or investigation, In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES . ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Prin Jennifer M. Axt, APRN, 2300 West Capital Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /�y. I � -:f -. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I April 9, 2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANQ IBC! SERVICES,' IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK Dt*PAR3��'bf HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL, R op f ." { , • DATE OF ISSUANCE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE_. CERTIFICATE OF DEATH C� STANLEY S. COOPER - 201503861 O Q v DEPA TMENTV AI H A LINCOLN, NEBRASKA HUMAN SERVICES 04/12/2013 :13 01536