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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 TRITE 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 le
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OP HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />1/8/2020
<br />LINCOLN, NEBRASKA
<br />ti02003/59
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Mary Patricia Voss
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December21, 2019
<br />�4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-28-25$5
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />ComintJ,:,ty Hospital
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />McCook 69001,,
<br />9a. RESIDENCE -STATE:'
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5a, AGE., Last Birthday
<br />(Yrs.)
<br />94
<br />• " 9d. STREET AND NUMBER
<br />. 1409 Hagge Avenue
<br />r§ 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />2 ❑ Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />e �11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />ts
<br />Francis Dunn
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mat Day,1
<br />December 4, 1925
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Red Willow
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10b. NAME OF. SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />LUVeme ; Voss
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Anna Whalen
<br />13. EVER tN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, Or Unk.) NO
<br />c
<br />8
<br />15. METHOD OF DISPOSITION
<br />®Burial 0 Donation
<br />Cremation 0 Entombment
<br />❑Removal ;❑ Other:(Specify)
<br />14a. INFORMANT -NAME
<br />Mary Jean Mohnike
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16a. EMBALMER -SIGNATURE
<br />Timothy R. Daum
<br />16b. LICENSE NO.
<br />1253
<br />16c. DATE (Mo., Day, Yr.)
<br />December 28, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />0
<br />-a
<br />.rs
<br />0
<br />eG
<br />CITY I TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />O. PART I. Enter tit► chain of events -.diseases, injuries, or complications -that directly caused the Math. DO NOT enter temtinal 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 N necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Solitary Plasmaytoma Of Right Sacrum
<br />disease or condition rss',hlr'
<br />In death)
<br />Sequentially list condhlons,11
<br />any, leading to the cause tuned
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />b)
<br />Enter the UNDERLYING CAUSE C)
<br />(disesse or Injury that initiated:
<br />the events resulting in dear')
<br />LAST:
<br />STATE
<br />Nebraska
<br />17b68.Zip(
<br />801
<br />APPROXIMATE INTERVAL:
<br />onset to death
<br />6 Weeks
<br />onset to death
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />onset to dea
<br />h
<br />5 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Anemia, Hypokalemia, Acute Kidney Failure
<br />to
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />t? ❑ Pregnant at time of death
<br />0afl
<br />0 Not pregnant, but pregnant within 42 days of death
<br />i1 ❑ Na pmgnaat, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 HomiCide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21h. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />me=(swesy)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE).
<br />TO COMPLETE CAUSE Of DEATH?
<br />❑ YES ❑ NO
<br />w I22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />Nti' ] YES ❑ NO
<br />rf
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ATION OF INJURY STREET & NUMBER, APT.NO.
<br />30. DATE OF DEATH IMo., Day, Yr.)
<br />December 21, 2019
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH
<br />December 26, 2019 05:47 PM
<br />23d. To the best of my knowledge, death occurred at the time. date and place
<br />and due to the causes) stated. (Signature and Title)
<br />Kristtrl M. Fulkerson, MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion Math occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tide)
<br />26a. HAS ORGAN OR TISSUE ++ ATioN BEEN CONSIDERED?
<br />❑ YES i7NO
<br />127. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kristin M. Fulkerson, MD, 1401 East H Street, McCook, Nebraska 69001
<br />28a. REGISTRAR')
<br />SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR MMa,,Day, Yr.)
<br />January 3, 2020
<br />
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