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<br />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 REqOIJ-RPf./ FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTmJr5ECtif}N.~f'!t!'CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . --,=-.- ~..." '.~". '_l.='/tlZ:==:-o
<br />
<br />DATEDFmsUANCE ~T~~
<br />DEe 1 3 2005 200,602229 AlJSISTAiliSfmBsGISfflNl
<br />LINCOLN, NEBRASKA ~E~Lm~Nk~~~'~s
<br />-
<br />c. ._.
<br />--
<br />- .
<br />
<br />STATE OF NE. BRASKA - D.. EPARTMENT OF HEALTH AND H..U MAN SERVIC. E. S FiNANCEANOSUPPORT .... 3 4 51
<br />-- . CERTI'=-!9ATE OF= DEATH._; .. 05 --J
<br />
<br />(Firsl, Middle, Last. SuIII><)2, SEX 3, DATE OF DEATH (Mo" Day, Yr.)
<br />Verless Frieda VanWinkle Female November 25. 2005
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5., AGE.Lasl Birthday
<br />(Yrs,)
<br />
<br />5b. UNDER 1 YEAR
<br />MOS, DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURSCINS
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />Cairo, Nebraska
<br />
<br />85
<br />.=r=. . Ba. PLACE OF DEATH
<br />
<br />
<br />~-
<br />
<br />..--..- ".
<br />
<br />Q Olher (Specily!
<br />
<br />Septem~_~r 6,
<br />
<br />1920
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />507-92-2559
<br />
<br />0ll::Iffi:
<br />
<br />ClV-lursing Home/LTC LJ Hospice Faciiity
<br />
<br />Q Inpallent
<br />
<br />Bb. FACILITY-NAME (II nol institulion, gllle slreet and number)
<br />
<br />Q ER/O"lpetient
<br />
<br />Q DeceMnt's Home
<br />
<br />Beverly Healthcare Park Place
<br />
<br />80. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 68803
<br />
<br />Q[(lI\
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />-~YoATOWN -
<br />_~and Island
<br />- ~-- ge APT NO - 9f ZIP CODE =rg INSIDE CITY LIMITS
<br />68803 m YES Q NO
<br />--- - --~ .~
<br />lOb. NAME OF SPOUSE (Flrsl, Middle, Lesl, Suflix) If wile, give maiden name.
<br />
<br />9a. RESIDENCE-STATE 9b. COUNTY
<br />
<br />Nebraska Hall
<br />
<br />9d. STREET AND NUMBER
<br />610 North Darr Avenue
<br />
<br />10a. MARITAL STATUS AT TIME OF DEATH Q Married Q Nover Married
<br />
<br />U Merrled, but separaled Zl Widowed U Dlvorcod Q Unknown
<br />
<br />Kenneth VanWinkle
<br />
<br />11. FATHER'S.NAME (Flrsl.
<br />
<br />Middlo,
<br />
<br />p(Burial
<br />
<br />o Donation
<br />
<br />200
<br />
<br />Q Cremalion Q Enlombment 16d. C
<br />
<br />Q Removal Q Olher (Specily)
<br />__,_______ "'. _~~~_ Pleasant Ceme~ery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, Stale)
<br />
<br />1123 West 2nd Street Grand
<br />
<br />Cairo
<br />
<br />Nebraska
<br />
<br />
<br />PART I. Enter the MailLot ~yerJ.l.~--disBasas, injuries, or complicallons--that directly caused the death. DO NOT enter terminal events such as cardiac arrast,
<br />,e.piralory arra.l, or venlrlcular IIbrlllalion withoul 'howing the etiology. DO NOT ABBREVIATE. Enler only one cau,e on a line, Add addllionalllnas if necassary.
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />
<br />::MED~.ku,u!- PYU2Umauu~
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsello dealh
<br />
<br />onset to death
<br />
<br />.5 ~ S::.
<br />
<br />Sequentially list condlllona, If (b)
<br />ony,leodlngtothecousellsted DUE TO~OA-AS A CONSEOUENCE OF:
<br />online..
<br />Enterthe UNDERLYING CAUSE
<br />(disease or Injury thot Initialed (c)
<br />theevonts resulllng In deoth) DUE TO, OR AS A CONSEOUENCE OF:
<br />LASr
<br />
<br />onsello death
<br />
<br />onsello de'lh
<br />
<br />Id)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Condlllon, contributing 10 Ihe death buf nol reaultlng in Iho underlying cause given in PART I.
<br />
<br />V to cu.fctA-.- ~a...
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />Q YES 'xl NO
<br />
<br />20. IF FEMALE:
<br />
<br />21 a. MANNER OF DEATH
<br />),!;(Nalural U Homicide
<br />
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />Q Drlver/OperalOr
<br />
<br />[J Passenger
<br />
<br />PJ. Not pregnant within pasl year
<br />Q Pregnant alllme of dealh
<br />Q NOI pregnant, bul pregnant wilhln 42 day. of dealh
<br />Q NOI pregnanl, bul pregnant 43 days 10 1 year before dealh
<br />U Unknown il pregnant wlll1lnlhe past year
<br />-22a -DATE OFINJURY (MO, Day, Yr~TIME OF INJufl:
<br />
<br />22dlNjURY ATWORK? - ] 22e DESCRIBE HOW INJURY OCCURRED
<br />Q YES U NO
<br />- - -" ~-
<br />221. lOCATION OF INJURY - STReET & NUMBER, APT. NO.
<br />
<br />Q AccidenlU Pending Invesligalion
<br />
<br />Q YES
<br />
<br />i(NO
<br />
<br />o Pedestrian
<br />Q Other (Specify)
<br />
<br />Q Suicide Q Could nol be dSlermlned
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES ~NO
<br />
<br />22C, Pt,ACE OF INJURY.AI home, larm, a,,.et, faolor,t:bfllco bulldlng, oonst,uo1lon slla, 1!1C, (Speelfy)
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a:p~E ~F DEATH (M2!' ?ay, Yr.)
<br />y{ ~ .,riS', ,20t:tr
<br />_.'~.'."---~.,,,,,._-_.
<br />2~DATE SIGNED (Mo., Day, Yr.)
<br />/( &t/'. -30, ::J.O Clr"
<br />
<br />240. DATE SIGNED IMo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />>~~
<br />.cuz
<br />'lliiigj
<br />->1:
<br />!it<l~
<br />E .~ 1: z
<br />8[5,.0
<br />~z::>
<br />"'00
<br />~a:O
<br />815
<br />
<br />m
<br />
<br />ct,m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On lhe basis of examinatlon and/or Investigation, in my opinion death occurred at
<br />the lime, dale and place and duelo Ihe cause(s) slaled. (Slgnalure and Tille) T
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />N~I Applicabl. if 26a 19 NOQ YES '\l;l' NO___
<br />
<br />Q YES ':Id NO Q PROBABLY Q UNKNOWN Q YES ~ NO
<br />27, NAME, TITLE AND ADD-RESS OF CERTIFIER (PHYSICIAN, CORClNEfl'S PHYSICIAN OR COUNTY ATTORNEY) (TypeorPrlnt)
<br />
<br />ichar
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />[lEG ~- G 2005
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