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<br />STATE OF NEBRASKA
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<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 />11/2/2017
<br />LINCOLN, NESRASKA
<br />. 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />o Grand island. 68803
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<br />r 13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />8 (Yes, No, or unk.)NO
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal .0 Other(Specify)
<br />201804464
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH; AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />aye
<br />STANLEY S. €DOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />dd. COuN T't op DEATH
<br />Hall
<br />td
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jeanette Rae Vogt
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508 48 -1971:
<br />Sb. FACILITY -NAM;E (Knot Institution, give street and number)
<br />4326 Cambridge Rd
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />76
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 16, 2017
<br />November 24, 1940"
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />Hospice Facility
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4326 Cambridge Rd
<br />19a. MARITAL STATUSAT TIME OF DEATH ® Married ❑ Never Married
<br />❑Married, but separated' ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Maurice Griffin
<br />I 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Jessie Lowell
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)(
<br />All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />16. PART!. E nter the chain of events- - diseases, injuries, or complications -that directly caused: the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or VeetriCular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) C ardiac Arrest
<br />4 .seas. nr _. itb res._..
<br />CAUSE OF DEATH (See instructions and examples)
<br />APPROXIMATE INTERVAL ...
<br />onset to death
<br />Minutes
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />seguentiallypatoordidons, b) Degenerative Heart Condition
<br />any, teadingle the cause Naiad ?'
<br />on line 'a •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EMerthe UNDERLYING CAUSE c) High Blood Pressure
<br />(disease or i1Vury that initiated
<br />onset to death
<br />the events Mann in Sea
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Diabetes
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE: N
<br />0 Not ptegnant within past year
<br />❑ Pregnant at time of death
<br />❑ NM ptegnaM;:but 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 :IAIORJ(?
<br />❑YES QNO
<br />9b. COUNTY
<br />Hall
<br />16a. EMBALMER- SIGNATURE
<br />Katie M. Smvdra
<br />22b. TIME OF INJURY
<br />14a. INFORMANT -NAME
<br />Allen Dale <Vo•t
<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 />Grand Island
<br />9e. APT. NO.
<br />b LICENSE NO.
<br />1454
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver /Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS"
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden na
<br />Allen Dale Vogt
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (Mo., Day, Yr.)
<br />October 20, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Prairie Center
<br />CITY I TOWN
<br />Haven's Chapel
<br />STATE
<br />Nebraska'
<br />19. WAS MEDICAL. EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE ZIP CODE'
<br />23c. TIME OF DEATH
<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 />25. DIP TQBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO 0 PROBABLY ® UNKNOWN
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<br />24a. .E 01,1a., Day, Y:.)
<br />October 17, 2017
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES Ed NO
<br />24 TIME OF DE TH
<br />Approx. 12 :01 PM
<br />October 16, 2017 05:13 PM
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Gail VerMaas, Hall Deputy County Attornev
<br />28b. DATE FILED BY REGISTRAR{
<br />October 25, 2017
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gait VerMaas, Hall Deputy County Attorney, 231 S Locust P.O. Box 367, Grand island, Nebraska, 68802
<br />28a. REGISTRAR SSIG NATURE /1,+ / - % cr
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