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ITZRPtit STATE OF NEBRASKA zsrgyinvIM v re re 5 w Z:. ,o 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Dorothy Lee Heckman 4. CITY WHEN < THIS '' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 1/1 7/20 1 7 LINCOLN, NEBRASKA AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 507 -34- 5314 813. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Wood River 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River..: 688.83 I: RESIDENCE -STATE 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 409 W Egypt 1 Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated" ❑ Widowed ❑ Divorced ❑ Unknown 1 t11. FATHER'S -NAME (First, Middle, Last, Suffix) Wesley Elliot Sorensen 3,; EVER IN U.S. ARMED FO RCES? Give dates of service if Yes. (Yes, No, or link.) NO 5. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal Q Other(Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home, 601 N. Webb Road. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) ,f 1. Enter the Chain at events diseases, injuries, or complications -that directly caused thedeath.DO NOT enterterninal events such as cardiac arrest, spiratory arrest, or ventrrcilar 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) Respiratory Failure disease or condition resulting in death) 16a. EMBALMER - SIGNATURE Gwen K. Hyronemus 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park DUE TO, OR AS A CONSEQUENCE OF: sequentially list 4d ditiona, if b)Alzheimers Dementia any, leading to the gauss listed on line Enter the UNDERLYING. CAUSE (disee4e •or injury dy3t amtrated the events resuhinji yin death) 22a. DATE OF INJURY (Mo., Day, Yr.) d,:INJURY AT WORK? .:< ❑YES ❑NO 3 F re z J O 23a. D.A. TE OF OEATH (Mo., Day, Yr.) December129, 2016 23 b. DATE SIGNED (Mo., Day, Yr.) December 30, 2016 1 28a.)tEGISTRARS SIGNATURE STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF (HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DUE TO, OR AS A CONSEQUENCE OF: C) OUE TO, OR AS A CONSEQUENCE OF: d) L. IF FEMALE- . ❑ Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant,but pregnant within 42 days of death ❑ Npt pregnant • ptegna days to 1 year before death ❑ ttnkndwn itprggnant within the past year 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 23c. TIME OF DEATH 12:50 AM 20170269 5a, AGE - Last Birthday (Yrs.) 84 10b. NAME OF SPOUSE (First, Middle, Last, Richard Heckman 12. MOTHER'S -NAME (First, Helen Louise Hulett 14a. INFORMANT -NAME Richard Heckman 18. PART 1I. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITYITOWN aa. E v , 23d. To the best of my knowledge, death occurred at the time, date and place u w z and due to the cause(s) stated. (Signature and Title) g z Jennifer L. Brown, MD o !° 25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 10 NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jennifer L. Brown; MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803;, 5b, UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9e, CITY OR TOWN Cairo O DAYS 1448 9e. APT. NO. HOURS OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 16b. LICENSE NO. 2. SEX Female 5c. UNDER 1 DAY CITY I TOWN Grand Island 9f. ZIP CODE 68824 1b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other_1Specify) STATE 4a. DATE SIGNED (Mo., Day, Yr.) coviti MINS. 3. DATE OF DEATH (Mo., Day, Yr.) December 29, 2016 6. DATE OF BIRTH (Me., Day, Y r.)'; October 8, 19 Suffix) If wife, give maiden name Middle, Maiden Surname) onset to death > 1 Year onset to death 24b. TIME OF DEATH 24e. On the basis of examination and /or investigation, in my opinion death occurred . the time, date and place and due to the cause(s) stated. (Signature and Mel ❑ Hospice Facility 28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.} January 6, 2017 l 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) January 3, 2017 STATE Nebraska 17b, Zip Code 68803 APPROXIMATE INT onset to death < 1 Day ZIP COD onset t0 death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 10 NL) 21c. WAS AN AUTOPSY PERFORMED/ ❑ YES Lid NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF'DEATH? ❑ YES ❑ NO 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED Not Applicable if 26a is NO ❑ YES ❑ NO