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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND-mJfrA7 SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA J3EPAR''MENT OF FIEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL,RECORDS.
<br />DATE OF ISSUANCE
<br />05/24/2012
<br />LINCOLN, NEBRASKA
<br />201704617
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES'
<br />STANLEY'S, cQOP R
<br />ASSISTANT .S'�",4 E R
<br />DEPARTMEN* Mt i
<br />KUMAI Z SERV CES
<br />., A
<br />vr_n I rsae" t Q Jr - LIMP %U n
<br />1. oeceoi NTSNAME (First.. Wel% 1.aat cilium/
<br />LuVeme Ray Voss
<br />2. SEX:..
<br />Male
<br />a 1 E- lr 1 77 .) 4
<br />: 3. DATE OF DEATH (Mo ..Dry,Yr.)
<br />May 17,'2012
<br />l CRY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Se. AGE•I.ast Birthday
<br />(Ye..)
<br />86
<br />lib. UNDER 1 YEAR
<br />8e. UNDER 1 DAY :
<br />I. DATE OF BIRTH (Mo., Day, Yr.)
<br />S`
<br />February 4, 1926
<br />Ashland, Nebraska
<br />N
<br />DAYS
<br />HOU
<br />IONS.
<br />7. SOCIAL. SECURITY NUMBER
<br />507 -20 -1706
<br />S.. PLACE OF
<br />g g s p n A r .
<br />DEATH
<br />® Inpos.a plunk° it miss HwnNLTC ❑ Haaptee Facility
<br />Ob. FACILITY-NAIME at not IngMMon, give street end number)
<br />Veterans Affairs Medical Center
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />0 ENOMP 1018111 ❑
<br />0 00N► 0OtharISpaCE11
<br />Decedents Noire
<br />> COUNTY OF DEATH
<br />Hall
<br />N. IBESIDENCE -STATE
<br />Nebraska
<br />Sb. COUNTY
<br />Half
<br />Sc. CITY OR TOWN
<br />Grand island
<br />red. STREET AND NUMBER -.
<br />1409 Hagge Ave
<br />(Float,
<br />Dunn
<br />N. APT. NO.
<br />W. CODE:
<br />86801
<br />wife, give maiden name.
<br />9S. r181D! CITY LIMITS :.
<br />El Yet O No
<br />10a. MARITAL STATUS AT TIME OF DEATH : ®Narded 0 Nawr
<br />❑ loaded, but *spiraled ❑ ywdowed 0 Divorced :0 Unknown
<br />lab. NAME OF SPOUSE
<br />Mary Patricia
<br />Middl, Last, Suffix) I
<br />11. FATTER'S4IAME (First S Middle.. Last, S Nix) -
<br />John Voss
<br />- 12. MOTHER'S•NAME (First, Middle. Maiden l amain. ) :.
<br />Agnes Freida Krahmer
<br />13. EVER IN U.S. ARMED FORCES? Give del.. of service x Yes.
<br />(Yes. No. or Unk.)> Yes 06/09/1944.06118 /1946
<br />110 WFORMANTHNAME :..
<br />Mary Patricia Voss
<br />14b: RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION .
<br />®avow ODprdao
<br />OCaetson <❑Embedme t
<br />a : ;0 00- tame»
<br />1N. EMBALMER- SIGNATURE
<br />/ T
<br />: I -�.
<br />: ISb. LICENSE NO. / , � :
<br />/
<br />10c. DATE (Mo., Day, Yr.)
<br />May 22; 2012
<br />.
<br />1St CEMETERY, CREMATORY OR OTHER L CITYROWN : STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Street City or Town, State) .;
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />170 ZIP Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />II. PART I gain I ie nalbAttlille -dee , puYNe, or ean-arsionnit t*tub cord Be death. DO NOT order wrwk,.levents swab martist arrest ' APPROXIMATE INTERVAL
<br />nmemeey mutt rw.MCdrIBMedbn wW.r.eMwia rwMldoW DO NOTA l1ANVIAIE. SEWN aery one muse se a Ent. Add adllbnel Into It nesneery.
<br />IMMEDIATE CAUSE: ' onset todath - .
<br />IMMEDIATE CAUSE (Fold (� : - r
<br />disuse in death) DDIIdItlo111amllog •) `.lif k e...%10 C ork �Q ,, \,Ar'�
<br />DUE TO, OR AS A CONSEQUENCE OF: ` :onset to death
<br />Sequential 1117 G 0 G 0101011 0 o E ` y. rya i
<br />any. lading to de Cana* IlsIod : 4) A S ( % V. \ e (1 \ 1_\.4 lrtIN 1 a
<br />on Ern a DUE TO, ORASA SEQUENCE OF: 1 onset to dealt
<br />Einar IM UNDERLYING CAUSE a) ` , 1 . VC�� �1S � Q � 4 m. Q Q � r e -
<br />that INtlated
<br />wise. a wary ,
<br />the was rardSnatn Matld <: DUE TO, OR AS A CONSEQUENCE OF: , onset to death
<br />LAST n
<br />d) N. 0.\
<br />tit. PARTS. OTHERSIGNIF)CAt ccIiDmOMS•CmrdSam wMdbudnp tome death but not reonddng b the underlying cause given In PART L
<br />(� 1 C
<br />e r F
<br />e_ r ne1 CT�1 ►Se O. ca. ►�Cn�rs GMl 'i,sm oij CAI,NYN�
<br />1e. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0
<br />20. F # EMALE:
<br />Diet t pregnant
<br />preg t within past year
<br />❑Pregnant at thne of death '..
<br />ONotpregnent but pregnant within e.2 days educe
<br />0 pmpnrtt but pregnant 43 days to 1 year before death
<br />❑UNmown If pregnant within to past year
<br />21.. BANNER OF DEATH `
<br />flatting flatting
<br />0 'm 0 Homicide
<br />'Aaldwd 0 Pending Mnatlwlon
<br />Icide 0 Could not be. debts seined
<br />210. IF TRANSPORTATION INJURY
<br />El pdyddOpwamr
<br />' ❑ Passenger
<br />:❑ Pedestrian
<br />: 00Mar(Spaetry)
<br />310 WAS AN AUTOPSY PERFORMED?
<br />❑ YES VNO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 „ :. )(140 :.
<br />�+1�
<br />22.. DATE OF INJURY (Mo, Day, Yr.)
<br />pet N_ 1 II . a of a
<br />22b. TIME OF INJURY
<br />41$0 f i m
<br />, 22c. PLACE OF INJURY -At hone, farm, :ab e%tedd y, ollas building, conaluetla site, eta. (Specify) '.
<br />o rcc
<br />22d. INJURY T WORK?
<br />ID Tea
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />N.a \1
<br />2e. LOCATION OF INJURY- STREETS NUMBER, APT. NO. CITYITOWN STATE >. ZIP CODE
<br />N 69 \14 . G. t (r and 7.,, tsit_br4a to 8,0 I
<br />gt
<br />g
<br />23. DATE OF DEATH ( ;Day, Yr.)
<br />n04 V clola
<br />, l
<br />24a. DATE SIGNED(Mo., Day, Yr.)
<br />240. TIME OF DEATH
<br />m
<br />Y 2]b. DAT�KiNED (MDR, Day, Yr.) 23c. TIME OF DEATH
<br />,,,al Z:ao P
<br />_ 1 Q }
<br />-tea-.(g
<br />7.44. PRONOUNCED DEAD IMO.. Yr)
<br />24d. TIME PRONOUNCED DEAD
<br />t3 a... '
<br />D W
<br />. of my n. yi -'. at the WD%, del. mm Plots S M.
<br />32d. • . m
<br />'i -: - �' .3 � g
<br />I
<br />2 e. On the basis of examinelon anew Investigation, In my opinion death occurred `.
<br />piece and d to the cause(s)stated. (Signature and lids)
<br />at t s lime. date and e. r�
<br />2e.. DD TOBACCO To THE DEATH? 20e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES �NO 0 PROBABLY ❑ UNKNOWN ❑ YES .$ NO
<br />211b. WAS cows Ir GRANTED?
<br />Not ApplomeN It 205 1. 2 NO ❑ YES > TR
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Pte)
<br />MI\ otr`k - 1QIIIA,Pwk '? M n. i r C ( ir1 Ntbce c I. 2ij') - 4aO1 N -Coll Weil
<br />38EG. TRARIt IG
<br />SNATURE 4 y i /
<br />I 0 R ,.
<br />P
<br />280. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAY 212012
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND-mJfrA7 SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA J3EPAR''MENT OF FIEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL,RECORDS.
<br />DATE OF ISSUANCE
<br />05/24/2012
<br />LINCOLN, NEBRASKA
<br />201704617
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES'
<br />STANLEY'S, cQOP R
<br />ASSISTANT .S'�",4 E R
<br />DEPARTMEN* Mt i
<br />KUMAI Z SERV CES
<br />., A
<br />
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