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STATE OF NEBRASKA
<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 ORIGINAL REGORD GAL FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTS 6WTIOkICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />DATE OF ISSUANCE N =_
<br />kY
<br />SEP 0 7 2005 200509170
<br />_ L'S. CpQPFR. ...'. ._... _ ...
<br />A�SI$rAH1"rST/kT'�= A�GI�TR�R
<br />LINCOLN, NEBRASKA HEALff-AND'HUMANS�IC.WS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND .-SUPPORT
<br />CERTIFICATE OF DEATH 06142
<br />1. DECEDENT'S -NAME (First. Middle, Last, Suffix) 2. SEX :C 3. DATE OF DEATH (Mo., Day, Yr.)
<br />John Loy Woldruff Male May 25, 2005
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-1-fist Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo,, Day, Yr,)
<br />(Yrs.) MOS. DAVS HOURS MIN5.
<br />Clarinda, Iowa 62 January 23, 1943
<br />7, SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br />480 -52 -6496 HOSPITAL; ❑ Inpatient OTHER: ❑ Nursing Home /LTC ❑ Hospice Facility
<br />815. FACILITY -NAME (If not institution, give street and number)
<br />❑ ER/Outpatient IN Decedent's Home
<br />601 Saturn ❑ Dp ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Alda 68810 Hall
<br />9a. RESIDENCE•STATE 9b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Alda
<br />9d. STREET AND NUMBER ge.APT.NO 9l. ZIP CODE 9g. INSIDE CITY LIMITS
<br />601 Saturn 68810 IX YES ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH Married LJ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give malden name.
<br />❑ Married, but separated El Widowed ❑Divorced UUnknown Linda Jaixen
<br />11. FATHER'S -NAME (First,
<br />Middle, Last, Suffix)
<br />12. MOTHER'S•NAME
<br />(First,
<br />Middle, Maiden Surname)
<br />Kenneth
<br />Woldruff
<br />Viola
<br />ar OR CORONER CONTACTED?
<br />Miller
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />148. INFORMANT•NAME
<br />❑ YES NO
<br />20, IF FEMALE:
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no, orunk.) No
<br />- ---
<br />Linda Woodruff
<br />--- - -- --- -.._....._._,.._...... .........
<br />Natural ❑ Homicide
<br />Q Driver /Operator
<br />Wife
<br />................___
<br />15. METHOD OF DISPOSITION
<br />168. EM - SIGNATU
<br />16b. LICENSE
<br />No.
<br />LJ Not pregnant, but pregnant within 42 days of death
<br />16c. DATE (Mn., Day, Yr. )
<br />C3 Burial ❑Donation
<br />-
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />El Other (Specify)
<br />May 31, 2005
<br />sXkremalion ❑ Entombment
<br />16d. CEMETERY, CRE ORY OR OTHER LOCA 0
<br />_1191
<br />CITY 1 TOWN
<br />STATE
<br />❑Removal ❑ Other (Specify)
<br />Westlawn Memorial Park Crematory,
<br />Grand
<br />Island, NE
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stale)
<br />117b. Zip Code
<br />Livingston- Sondermann. Funeral Home, 601 N. Webb Road, Grand Island, NE 168803
<br />18. PART I. Enter the chain o(- eyen-4- Alsensas, Injuries, or complications.-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, or ventrfcular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Imes if necessary.
<br />�. IMMEDIATE CAUSE,` II: _ c� _ j onset to death
<br />IMMEDIATE CAUSE (Final (a) VT- i"� /G- CCU CAL V2_U_([_rt . lower lobe of - -(�4�� 1990
<br />disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: lung i onsettodifath
<br />In death) I
<br />Sequentially list conditions, N
<br />any, lending to the cause listed
<br />on line a.
<br />Enterthe UNDERLYING CAUSE
<br />(disease or Injury that Initiated
<br />the events resulting In death)
<br />LAST
<br />(b)
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />(cJ
<br />DUE TO, OR AS A CONSEQUENCE OF'
<br />I
<br />I
<br />I onset to death
<br />I
<br />I onset to death
<br />I
<br />(d)
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />z y
<br />_..
<br />18. PART fl. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />19, WAS MEDICAL EXAMINER
<br />r //jj
<br />y
<br />23b. DATE SIGNEDIMho., Day, Yr.) r..
<br />ar OR CORONER CONTACTED?
<br />,(�JjJ-
<br />E z
<br />A- c r Cb
<br />❑ YES NO
<br />20, IF FEMALE:
<br />21a. MANNER OF DEATH
<br />21b.IFTRANSPORTATIONINJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ Not pregnant within past year
<br />Natural ❑ Homicide
<br />Q Driver /Operator
<br />❑ YES NO
<br />❑ Pregnant at time of death
<br />❑ Accident❑ Pending Investigation
<br />L) Passenger
<br />fu -
<br />LJ Not pregnant, but pregnant within 42 days of death
<br />❑ suicide ❑ Could not be determined
<br />11 Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />El Other (Specify)
<br />COMPLETE CAUSE OF DEATH?
<br />© Unknown If pregnant within the past year
<br />Cl YES U NO
<br />--------------------- .---- .
<br />22a. DATE OF INJURY (Mo.. Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />__ ....................___. _.................
<br />1 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d.INJURYATWORK? 22e.DESCRIBE HOW INJURY 000URRED
<br />❑ YES Cl NO
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN
<br />STATE ZIPCODE
<br />24a. DATE SIGNED (Mo.. Day, Yr.) 24b. TIME OF DEATH
<br />M
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />ITT
<br />24a. 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 />a n ob
<br />25. DIDTOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? k WAS CONSENT GRANTED?
<br />D YES X NO ❑ PROBABLY ❑ UNKNOWN V YES NO Not Applicable it 25a is NO ❑ YES )V NO
<br />2 . NAME,TITLE AND ADDRESS OFCERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (1`112A orP
<br />r f e 2/1 to # q00 r ild 13 a4d. fed
<br />28s. REGISTRAR'S SIGNATURE � I �, 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAY 3 12005
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />z y
<br />�S2
<br />May 25, 2005
<br />p:5�
<br />y
<br />23b. DATE SIGNEDIMho., Day, Yr.) r..
<br />23c.TIME OF DEATH
<br />g' i
<br />E z
<br />A- c r Cb
<br />12 Mid.
<br />Ho
<br />23d.To the best of my knowledge, death occurred at the time, date and place
<br />p
<br />ao
<br />F
<br />and due to the cause(s) stated. (Signature and Title) ♦
<br />FpCU
<br />STATE ZIPCODE
<br />24a. DATE SIGNED (Mo.. Day, Yr.) 24b. TIME OF DEATH
<br />M
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />ITT
<br />24a. 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 />a n ob
<br />25. DIDTOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? k WAS CONSENT GRANTED?
<br />D YES X NO ❑ PROBABLY ❑ UNKNOWN V YES NO Not Applicable it 25a is NO ❑ YES )V NO
<br />2 . NAME,TITLE AND ADDRESS OFCERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (1`112A orP
<br />r f e 2/1 to # q00 r ild 13 a4d. fed
<br />28s. REGISTRAR'S SIGNATURE � I �, 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAY 3 12005
<br />
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