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STATE OF NEBRASKA 201605245 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH'I THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE SEP 1 9 2007 LINCOLN, NEBRASKA 22f. LOCATION OF INJURY - t '4,TANLEY S COOPER ASSIS ATER mats- 777A% HEALTH AND HUMAN „S *ltVIbES • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANDSU RP,pR CERTIFICATE OF DEATH 1. DECEDENT'S -NAME (First, Middle, Last, Michael Samuel Sorahan 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Concord, California 7. SOCIAL SECURITY NUMBER 506 -50 -0990 8b. FACILITY -NAME (It not institution, give street and number) Saint Francis Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 540 E. 11th St. 10a. MARITAL STATUS AT TIME OF DEATH Gi Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Thomas 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, or unk.) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ICI Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust St.,Grand Island, NE 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 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 (Final disease or condition resulting In death) Sequentially list conditions, if (b) any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated (c) the events resulting in death) UsSf 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. 20. IF FEMALE: CI Not pregnant within past year ❑ 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 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? Li YES ❑ NO 28a. REGISTRAR'S SIGNATURE IMMEDIATE CAUSE: (a) rnt.1 bfrb a.. (Jt L iLt vv c MK+ DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: (d) 23b. DATE SIGNED (Mo., Day, Yr.) tt -v} TREET & NUMBER, APT. NO. 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed 16c. DATE (Mo., Day, Yr. ) Sept_ 13, 2007 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Service, Gibbon, Nebraska 22b. TIME OF INJURY 23a. DATE OF DEATH (Mo., Day,Yr.) September 12, 2007 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ' YES ❑ NO ❑ PROBABLY ❑ UNKNOWN Last, Sorahan Suffix) 14a. INFORMANT -NAME Kathlienne Sorahan 21a. MANNER OF DEATH lit Natural 0 Homicide m ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY/ OWN 23c.TIME OF DEATH 07:30 a.m 23d. To the best of my knowledge, death occur ed at the time, date and place and due to the cause(s) stated. (Signatu e and Title ) • a I t/� 1 � A IL V1►w Wl h,e 5a. AGE -Last Birthday (Yrs.) 6 5 Suffix) 5b. UNDER 1 YEAR MOS. DAYS 2.EX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH QI CI (Inpatient EB Nursing Home /LTC ❑ Hospice Facility ❑ ER /Outpatient ❑ Decedent's Home ❑ 004 ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9e. APT. NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Kathlienne Kress 12. MOTHER'S -NAME (First, Lila Middle, Maiden Surname) Wald 16b. LICENSE NO. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian CI Other (Specify) 22c. PLACE OF INJURY -At home, fa m, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES N O 9f. ZIP CODE 68801 0 'p9g36 3. BATE QF DEATH (Mo., Day, Yr.) Sept. 12, 2007 6. DATE OF BIRTH (Mo., Day, Yr.) Jan. 25, 1942 14b. RELATIONSHIP TO DECEDENT wife n 6 Z 8 p 8 01 onset to death So IlW0 , - onset to death onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES X NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES L.NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES At NO It ZIP CODE 24b.TIME OF DEATH 24d. TIME PRONOUNCED DEAD m 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 ) • 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES A NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Anne K. Morse, 729 N. Custer Ave.,Grand Island, Nebraska 68803 28b. DATE FILED BY REGISTRAR (Mo., Day,Yr.) SEP 14 2007 9g. INSIDE CITY LIMITS ai YES 0 NO