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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN, SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG/NArWECO= -MF&X WITH .
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST q&x -w- N,--WIWHIS•
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE v _6
<br />12/30/2004 200505722 As�T � TEM R-
<br />LINCOLN, NEBRASKA HEALTH AND *016 11 , S`YSi M
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FE�ISTCEAND SUPPORT
<br />04
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />'3. DATE OF DEATH (Monin. Day. Year)
<br />Max K. Dudgeon
<br />Male
<br />December 23, 2004
<br />4. CITY AND STATE OF BIRTH p(not in US.A.. name cdunfryJ
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />8. DATE OF BIRTH (Monts, pay. Year)
<br />MOS. DAYS
<br />it
<br />5c. HOURS' MINIS.
<br />Belvidere Nebraska
<br />(Yrs.) 84 5b.
<br />8
<br />March 8, 1920
<br />7. SOCIAL SECURTIV NUMBER
<br />Be. PLACE OF DEATH
<br />507 -12 --3329
<br />HOSPITAL Inpatient OTHER: Nursing Home
<br />- --
<br />❑ ER Outpatient ❑ Residence
<br />Bb. FACILITY - Name Of not insritutiod, give Street and number)
<br />Nebraska Veterans Home
<br />❑ DOA ❑ other(Specdvi
<br />Be. CITY, TOWN DR LOCATION OF DEATH
<br />ad. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />.5c.
<br />Yea ❑X Nq ❑
<br />Ha71 _.__ _
<br />9a. RESiUEJUE - STATE -o. G:)UN fY ''
<br />I;IY i. TOWN On LOCAYioN
<br />5u. 5'i ;.tEl ANU NUMBER (Inducing Zip Code)
<br />9e: TNSIOE CRY LIMITS
<br />Nebraska Hall
<br />Grand Island
<br />2300 W. Capital Ave.
<br />Yes ® No ❑
<br />10, RACE - (e.g,, White. Black. American Indian,
<br />11. ANCESTRY (e.g., Italian. Mexican, German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />73. NAME OF SPOUSE (1/ wife, give maiden name)
<br />etc.) (Specify)
<br />White
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />MARRED
<br />Majda A. Jakimov
<br />14a. USUAL OCCUPATION /Give kwof work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only hgMN grade completed)
<br />o/working ll/ _ eve d 6v 1
<br />Assisant Postmaster
<br />U.S. Government
<br />Elementary or Secondary t0 -12) Col)gga n 4 or 5•I
<br />[ .
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />William Harrison Dudgeon
<br />Fern 0- Young
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FORCES? lI
<br />Ww
<br />19a. INFORMANT - NAME
<br />(Yes. no, or unk.
<br />Yes:
<br />pf yes. give war and dates of services)
<br />10 -1940 1 -16 --1945
<br />Majda Dudgeon
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />1027 South Eugene, Grand Island, NE 68801
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO,
<br />21 a. METHOD OF DISPOSITION
<br />21b, DATE 21
<br />c. CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />Dec. 26, 2004 Westlawn
<br />Memorial Cremator,
<br />[] Burial ❑Removal
<br />22d. FUNERAL HOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />®Cremation 1:1 Donation
<br />Grand Island, NE
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second, Grand Island, NE 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). IN, AND (d)) Interval between onset and death
<br />PI
<br />Cardiopulmonary Arrest 0
<br />le
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />(b) Vascular Dementia Many Years
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />(dl .,, ....... .... . _ -.
<br />-
<br />OTHER SIGNIFICANT CONDITIONS • Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS RASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10.54) Yes NO
<br />Yea No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day Yr.(
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />nAccident F-1 Undetermined
<br />M
<br />❑ Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />L�qq ��
<br />261. CBic9 E F,,IN p farm, street, factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />❑ Homicide Investigation
<br />Yes ❑ No ❑
<br />g. e�CV (At
<br />"
<br />27a. DATE OF DEATH (Mo,. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr)
<br />28b. TIME OF DEATH
<br />December 23, 2004
<br />M
<br />�aaa
<br />}S
<br />i K
<br />27b. DATE SIGNED /Mc.. Day. YrJ
<br />27c, TIME OF DEATH
<br />28C. PRONOUNCED DEAD /Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Hour)
<br />8_
<br />o
<br />�'Z�Z[� °D
<br />11:20 p.m.
<br />M
<br />�
<br />27d. To the best of my knoMcurred at the time,}�Ate and place and due to the
<br />28e. On the basis of examination and,or Investigation, in my opinion death occurred at
<br />causels) stated. / /)
<br />//�W.
<br />5
<br />the time, date and place and due to the causes) Stated.
<br />_L
<br />(Si nature and 7111e C
<br />nature and Tmel III
<br />29, DID TOBACCO USE CONTRI UTE TO THE DEATH? 30e
<br />HAS ORGAN OR TISSUE DONATION BEEN
<br />CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES ❑ NO UNKNOWN
<br />❑ YES I/ll
<br />NO
<br />❑ YES ❑ NO
<br />31, NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Prind
<br />Sheridan Anderson M.D. Gr ,,and Island Veterans Home, Grand Island, NE 68803
<br />322. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Md.. Day. Yr.)
<br />DEC 2 9 2004
<br />u
<br />Lip,: Fight (8) and the Northerly Twenty (20) feet of Lot Seventeen (17), Anderson Subdiv-i, ^ion
<br />an Addition to the City of Grand Island, Hall County, NEbraeaka
<br />
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