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STATE OF NEBRASKA
<br />+
<br />AUX, X'
<br />WHEN THIS . >'';COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />1/17/2017
<br />LINCOLN, NEBRASKA
<br />20170269.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEAL
<br />CERTIFICATE OF D
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />C H AND HUMAN SERVICES
<br />EATH
<br />m
<br />0
<br />2
<br />H
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Dorothy Lee Heckman
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Gra
<br />id Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-34 -5314:
<br />814, FACILITY -NAME (If not Institution, give street and number)
<br />Good Samaritan Society -Wood River
<br />9a, RESIDENCE -STATE
<br />Nebraska
<br />18a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />• ❑Married, but separated,; ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Wesley Elliot Sorensen
<br />43. EVER IN U.S.: ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No or Unk.) No
<br />45. METHOD OF DISPOSITION
<br />E Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />in' > death{
<br />Sequentially list CW)fhtiens, if
<br />any, tending to the cause listed!'
<br />on line a. •
<br />Enter the UNDERLYING CAUSE
<br />(disease dr Injury that inivate4
<br />the events resulting death)
<br />LAST
<br />20. IF FEMALE:
<br />❑ Not pregnantwithin past year
<br />❑ Pregnant at time of death'.
<br />❑ Not pregnant,;6ut pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />DYES ❑NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN
<br />. DATE OF DEATH (Mo., Day, Yr.)
<br />December.29, 2016
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 30, 2016
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Alzheimers Dementia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23c. TIME OF DEATH
<br />12:50 AM
<br />3d, To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Jennifer L. Brown, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 1J NO ❑ PROBABLY ❑ UNKNOWN
<br />5a, AGE - Last Birthday
<br />(Yrs.)
<br />84
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Wood River 68883
<br />9d. STREET AND' NUMBER
<br />409 W Egypt
<br />14b. NAME OF SPOUSE (First,
<br />Richard Heckman
<br />16a. EMBALMER - SIGNATURE
<br />Gwen K. Hyronemus
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston- Sondermann Funeral Home, 601 N. Webb Road. Grand Island. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />9c. CITY OR TOWN
<br />Cairo
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />HOURS
<br />9e. APT. NO.
<br />'28a. REGISTRA SIGNATURE
<br />Jai
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MINS.
<br />OTHER E Nursing Ho
<br />❑ Decedent's
<br />❑ Other (Spe
<br />8d. COUNTY OF DEATH
<br />Hall
<br />3.
<br />6
<br />9f. ZIP CODE
<br />68824
<br />Middle, Last, Suffix) If wife, gi
<br />k< 12. MOTHER'S -NAME (First, Middle, Maiden
<br />Helen Louise Hulett
<br />14a. INFORMANT -NAME
<br />Richard Heckman
<br />16b. LICENSE NO.
<br />1448
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Grand Island
<br />14. PART I. Enter the chant tff events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />2114. IF TRANSPORTATION INJURY
<br />0 Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />STATE
<br />26a. HAS ORGAN! OR TISSUE a JA11ON BEEN CONSIDERED?
<br />❑ YES ENO
<br />21c. WA
<br />0
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, cons
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d.
<br />24e. On the basis of examination and /or investigation, i
<br />the time, date and place and due to the causes) s
<br />26b. WAS CON
<br />Not Applicable if
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />December 29, 2016
<br />. DATE OF BIRTH (Mo., Day, Yr. }'.
<br />October 8, 1932
<br />me /LTC
<br />Home
<br />ify)
<br />ve maiden name:.
<br />Surname)
<br />❑ Hospice Facility
<br />9g. INSIDE CITY LBNITS
<br />j YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 6, 2017
<br />14b. RELATIONSHIP TO DECEDENT
<br />SoOUSe
<br />16c. DATE (Mo., Day, Yr.):
<br />January 3, 2017
<br />STATE
<br />Nebraska
<br />17b, Zip Co
<br />68803
<br />AF'PROXIMATE:INTERVAL
<br />onset to death
<br />< 1 Day
<br />onset tt4idea t
<br />> 1 Year
<br />onset to death
<br />onset to death:
<br />ZIP CODE"
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />SAN AUTOPSY PERFORMED?
<br />ES E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />El YES 0 N
<br />ruction site, etc, (Specify)
<br />TIME OF DEATH
<br />TIME PRONOUNCED DEAD
<br />my opinion death occurred at
<br />tod, (Signature and Title)
<br />SENT GRANTED?
<br />26a is NO ; ❑ YES ❑ NO
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