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MEN THIS COPY CARRES T1E RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTM f! CERTFES TM BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE `��ry(�� ANLEY S. COOPER 9/19/2003 200316152 ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT AMAT QTAI rcrrrc CERTIFICATE OF DEATH n3 10484 Interval between onset and death I 1. DECEDENT • NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Month. Day.. Year) Robert Michael Dorsey Jr Male September 4, 2003 4. CITY AND STATE OF BIRTH t)lrr0yn USA.. name counay) 5a. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH tMondn. Dray. Year) St, Joseph, Missouri (Yrs.) 82 5b. MOS.1 DAYS 5c. HOURS MINS. May 27, 1921 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH 479 -01 -8838 NOSPRAL ❑ Inpatient OTHER: Nursing Home ❑ ER Outpatient © Residence 8b. FACILITY - Name tNrrot instlNNon, give sheet and number) Home: 821 W. 1st St. ❑ DOA ❑ Other ( Spec4i 8c. CITY, TOWN OR LOCATION OF DEATH So. INSIDE CITY LIMITS' Be. COUNTY OF DEATH Grand Island Yea ® No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CRY. TOWN OR LOCATION 9d. STREET AND NUMBER tlndudingZip Code) 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 821 W. 1st St. 68801 Y.K] Nd ❑ 10. RACE - (e.g.. White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 12 © MARRIED ❑ WIDOWED 13. NAME OF SPOUSE ttl ante. givemaiden name) etc.1 (Soe %ihite (Swifyl American NEVER DIVORCED Anna Veronica McQuillan MA 14a. USUAL OCCUPATION /Give kkd olaork donne durhtgmasl 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) of working lik, even ilretired/ Salesman Desch Paine Monuments Elementary ondary 10 -12) Col a 11-4 or 5 -1 �-- 16. FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME 117 Robert Michael Dorsey Marie M. Burvenich 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT - NAME (YBYes: ') 194"271�50'sdfgeMcee) Sheila O'Day 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 2112 S. 135th Ave., Omaha, Nebraska 68144 20. EMBALMER - SIGNATURE 8 LICENSE NO. - 21 a METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME •jr� * /3�'r �Bunal ❑ Removal 9/08/2003 Sacred Heart Cemetery 22a. FUNERAL HOM - NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler - Geddes ❑Cremation ❑oonatxx, Greeley, Nebraska 22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 1123 West Second,` Grand Island, Nebraska 68801 _ 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR IaL (b), AND (q) Interval between onset and death PART immediate (al Heart Attack DUE TO, OR AS A CONSEOUENCE OF Interval between onset and death I Ib) I - DUE TO. OR AS A CONSEOUENCE OF: I Interval between onset and death I Icl I I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART 111 IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART II PREGNANCY IN THE PAST 3 MONTHS? EXAMINER CORONER? (Ages 10 -541 Yes No M Yes M No Yes No 26a. 26b. DATE OF INJURY tMO.. Day Yr.) 26c. HOUR OF INJURY 2E HOW INJURY OCCURRED Accident Undetermined M Suicide Pending 26e. INJURY AT WORK 26f. PLAe E?F, IN URY .Uhho.Tg, farm, street. factory ollfh b 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑. No ❑ ry) . 27a. DATE OF DEATH tMo.. Day. Yr.) 28a. DATE SIGNED (Mo.. Day. Yr.) 28b. TIME OF DEATH <Y September 11, 2003 2:00 am M �< r 27b. DATE SIGNED (Ma- Day. Yc/ 27c. TIME OF DEATH 28c. PRONOUNCED DEAD tMo.. Day, Yr) 28d. PRONOUNCED DEAD /Hour) Y y Q Ij g M J s�€ Sept 4, 2003 7:00 pm M 8 { i <t w 8 ° 27d. To the best d my knowledge. death occurred at the time, date and Place and due to Me 26e. On the basis of a mi on- on, in my opinion death oc/'+ ed at causelsl stated v a ae, the time, data a s) stems. D C 0 A t t Y Signature and Tale ► ISi nature and Ti6e 29, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS C014SENT GRANTED? ❑ YES ❑ NO n UNKNOWN ❑ YES n NO ❑ YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Print) Michelle Oldham, Deputy Hall County If Attorney, 231 S Locust, Grand Islar 32a REGISTRAR - 449114, 32b. DATE FILED BY iVfLPA R.,fM y)V NE V LU o3 - '1l