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WHEN THIS COPYGIRRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINIAL R(Ef ill F&iM 7TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIICfIlS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />MAR 2 8 2000 20010 2 10
<br />ASSISTAW STATE OR$T t=
<br />LINCOLN, NEBRASKA HEALTH AND Ht IMM' R1/ICE3 S`YSTEII€
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEi&1CBjji 4a1N AND S*'ORT
<br />VITAL STATISTICS _
<br />CERTIFICATE OF DEATH
<br />DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />r
<br />2
<br />Female'
<br />February 26, 2000
<br />CITY AND STATE OF BIRTH ll /no! in US A.. name counlryl
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />�s
<br />_
<br />6. DATE OF BIRTH IMontlr. Day Year)
<br />Sb. MOS. I DAYS
<br />5c HOURS MINS
<br />Ravenna, Nebraska
<br />D
<br />May 29, 1918
<br />SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />506 -18 -5141
<br />HOSPITAL. Inpatient E
<br />OTH R. Nursing Home
<br />— — p - --
<br />❑ ER Outpatient ❑ Residence
<br />C
<br />rn
<br />y
<br />_
<br />CITY TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® ❑
<br />rn
<br />28d. PRONOUNCED DEAD (Hour;
<br />U
<br />Februa 9,
<br />RESIDENCE - STATE
<br />9b COUNTY
<br />►-'
<br />o
<br />O
<br />Nebraska
<br />Hall
<br />=
<br />u�
<br />❑X ❑
<br />c ❑ YES � NO
<br />❑ YES ® NO
<br />z
<br />N
<br />�. RACE - (e.g,, White. Black American Indian
<br />11. ANCESTRY (eg.. Italian. Mexican. German, etc)
<br />t2. © MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE fit wde give maiden name/
<br />etc IISPecity) White
<br />11
<br />ISpecry) American
<br />1
<br />NEVER DIVORCED
<br />M R 1
<br />Paul P. Vodehnal
<br />a USUAL OCCUPATION /Give kindo, work done doming most
<br />14b KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working We. even dreereW
<br />Sales Lady
<br />Department Store
<br />Elementary or Secondary 10 -121 College 11 �4 or y•I
<br />11
<br />FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />�
<br />Anna May Whitcomb
<br />-< o
<br />tga. INFORMANT NAME
<br />Ye., nit [e unk.) III yes. give war and dates of ser aces)
<br />No
<br />Vernon Vodehnal - -
<br />.�.�
<br />CT)
<br />—n
<br />m
<br />O
<br />b a)
<br />O
<br />M
<br />r D
<br />CS?
<br />N
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<br />WHEN THIS COPYGIRRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINIAL R(Ef ill F&iM 7TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIICfIlS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />MAR 2 8 2000 20010 2 10
<br />ASSISTAW STATE OR$T t=
<br />LINCOLN, NEBRASKA HEALTH AND Ht IMM' R1/ICE3 S`YSTEII€
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEi&1CBjji 4a1N AND S*'ORT
<br />VITAL STATISTICS _
<br />CERTIFICATE OF DEATH
<br />DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /hforim Day ✓earl
<br />Wilma Ann Vodehnal
<br />Female'
<br />February 26, 2000
<br />CITY AND STATE OF BIRTH ll /no! in US A.. name counlryl
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />_
<br />6. DATE OF BIRTH IMontlr. Day Year)
<br />Sb. MOS. I DAYS
<br />5c HOURS MINS
<br />Ravenna, Nebraska
<br />IYrsl 81
<br />May 29, 1918
<br />SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />506 -18 -5141
<br />HOSPITAL. Inpatient E
<br />OTH R. Nursing Home
<br />— — p - --
<br />❑ ER Outpatient ❑ Residence
<br />r FACILITY - Name (N not institution, give street and numberl
<br />St. Francis Memorial Health Center
<br />❑ DOA ❑ Other(Spec,ty, _
<br />CITY TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® ❑
<br />Hall
<br />28d. PRONOUNCED DEAD (Hour;
<br />No
<br />Februa 9,
<br />RESIDENCE - STATE
<br />9b COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER /lncluddg Zip Code/
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1011 W. 9th 68801
<br />❑X ❑
<br />c ❑ YES � NO
<br />❑ YES ® NO
<br />Yes No
<br />�. RACE - (e.g,, White. Black American Indian
<br />11. ANCESTRY (eg.. Italian. Mexican. German, etc)
<br />t2. © MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE fit wde give maiden name/
<br />etc IISPecity) White
<br />11
<br />ISpecry) American
<br />1
<br />NEVER DIVORCED
<br />M R 1
<br />Paul P. Vodehnal
<br />a USUAL OCCUPATION /Give kindo, work done doming most
<br />14b KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working We. even dreereW
<br />Sales Lady
<br />Department Store
<br />Elementary or Secondary 10 -121 College 11 �4 or y•I
<br />11
<br />FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Edwin A. Kluge I
<br />Anna May Whitcomb
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />tga. INFORMANT NAME
<br />Ye., nit [e unk.) III yes. give war and dates of ser aces)
<br />No
<br />Vernon Vodehnal - -
<br />2813 North w st Ave., Grand Island, NE. 68803
<br />-fl E 21 a. METHOD OF DISPOSITION 21 b. DATE 21c CEMETERY OR CREMATORY NAME ® Burial ❑ Removal March 1, 2000 1 Grand Island Cemetery _ _ _
<br />'a UNERAL HOME - NA 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN S, ATE _ _ -
<br />Apfel- Butler - Geddes ❑ cremation ❑ Donatton Grand Island, Nebraska
<br />D FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE, ZIP)
<br />1123 West Second, Grand Island, NE 68801
<br />I. IMMEDIAT A SE ^��/ /� �/L� (ENT "ONNL�Y} ONE CAUSE PER LINE FOR ial. Ibl. AND (cl) erval between onset ani d7a -,
<br />PART V 1, �/ !�L{. -Ci 11 �O
<br />(al
<br />DUE TO, OP_t§ACONSEQUENCE OF / Interval between onset ano dean-`
<br />DUE TO, OR AS A CONSEOUENCE OF Interval between onset and death
<br />Id
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART PREGNANCY
<br />II
<br />111 IF FEMALE. WAS THERE A
<br />IN THE PAST 3 MONTHS
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO EDICAL
<br />EXAMINER OR CORONER?
<br />(Ages 1054) Yes No V
<br />Yes No
<br />Yes No
<br />.a
<br />26b. DATE OF INJURY (Mo.. Day Yr/ ' 05c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY O&UFIRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />7 Homicide Invesagatwn
<br />26e. INJURY AT WORK
<br />Yes No
<br />❑ ❑
<br />1 261 PACE OF INJURY - At home. farm street. factory
<br />oRlce budding. etc /Spec y/
<br />126g LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />27a. DATE OF DEATH (MO.. Day Yrl
<br />28a DATE SIGNED /Mo.. Day. YO
<br />28b. TIME OF DEATH
<br />February 26, 2000
<br />,<w
<br />i
<br />M
<br />27b. DATE SIGNED (Mo.. Day Yr./
<br />27c TIME OF DEATH
<br />28c PRONOUNCED DEAD (Mo.. Day, Yc1
<br />28d. PRONOUNCED DEAD (Hour;
<br />Februa 9,
<br />6.45 M
<br />•
<br />g¢=
<br />B °
<br />° a
<br />M
<br />27d To the best of my k wledge. curled at the ti tlate nd place and due to Ile
<br />causels) stated. 1/
<br />(Signature and Title P. vvLL
<br />_
<br />2. On the basis of examination and,or investigation, m my opinion dear occurred at
<br />the time, date and place and due to the causes) stated.
<br />(S� nature and Title ►
<br />I. DID TOBACCO USE CONTRIBU TO E DEATH?
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED'
<br />❑ YES NO ❑ UNKNOWN
<br />c ❑ YES � NO
<br />❑ YES ® NO
<br />John A. h D ;1 800 N. Alpha, Grand Island, NE 68803
<br />?a. REGISTRAR 32b. DATE FILED BY REGISTRAR (MO. Day. Yc/
<br />_ ...w n A •uulft
<br />•� rid
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