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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH A~NO-HI.1MJttv!t~VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIN~EC.OF!fJ fJN.~1YIT/d.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT~Tlf8-S.~R.1),ON,iV!J..1e!1. IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~C]". . ~~y 'i-~"-"}.~. ii:!J.:.'-'-'=':lf,~ ~
<br />
<br />DATE OF ISSUANCE . ...:' .~~i .~..~.
<br />OCT 1 1 2006 2 0 0 6 0 9 2 2 7 :'. .~', iANL-EYS. t:QOPfffl
<br />AS$1.STANT$TATEjlEq/StRAR
<br />LINCOLN, NEBRASKA HEALTH ANDtllJIlXN S}ERiVJOES
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<br />
<br />1. DECED~NT'S.NAME (First, Middle, Last, Sufllx)
<br />William Stanley Voyek
<br />
<br />4. CITY AND STATE OR TERRITORY, OR F~REIGN COUNTRY OF:]IRTH ;a~ AGE.Last Blrlhdey 5b, UNDER 1 YEAR
<br />(Yra.) MOS, DAYS
<br />Jackson Junction, Iowa 72
<br />
<br />- ~--- -- ---
<br />7. SOCIAL S~CURITY NUMBER 8a, PLACE OF DEATI!
<br />
<br />STATE OF NEBR.A. SKA - DEPARTMENT OF.. H.. EALTH AND HUMAN SERVICE. .S FINANCE AND S. .uPPol] 6
<br />. ___ .. CERTIJ=:ICATE OF. DEATH ... _
<br />
<br />30625
<br />
<br />2.SEX
<br />Ie
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr.)
<br />September 27,2006
<br />
<br />50. UND~R 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr,)
<br />
<br />April 15, 1934
<br />
<br />478-34-9601
<br />
<br />!iQWIAL
<br />
<br />o tnp.llent
<br />
<br />QIH..eJ: 0 Nursing Hom./LTC 0 Hospice FeoUlty
<br />
<br />8b. FACILITY.NAME (If nol Inslltution, glv. street and number)
<br />
<br />o ER/Oulpatient
<br />
<br />)i( Decedent's Home
<br />
<br />316 Brookline Dr.
<br />
<br />o CQr\ 0 Other (Sp.clfy)..
<br />8c. CITY OR TOWN OF DEATH (Include Zip Coda) -~Bd~OUNTY OF DEATH
<br />Grand Island 68801 ____..__.~ll
<br />
<br />------. - fb CQU;'all ~OWN~~and Isl~nd
<br />-~--- . ----- ..'-~NO 9~:;~DE_..=r:~~S~~:CITY~~:
<br />
<br />o Never Marrlod tOb. NAME OF SPOUSE (Firsl, Middl., Lasl, Suffix) II wile, giva maiden name.
<br />
<br />[J Married, but soparaled 0 Widowad U Dlvo,cad 0 Unknown
<br />
<br />Donna R. Barnes
<br />
<br />11, FATHER'S.NAM~ (Flrsl, Mlddla, La,t, Suffix) 12, MOTHER'S.NAME (Fir.t, Middle, Maiden Surname)
<br />William Mike Voyek Veronica Anna Krall
<br />
<br />13, EVER IN u,s, ARMED FORCES? Give dales of service if yas. 14e,INFORMANT.NAME . -----314b RELATIONSH'IP TO DECED~NT
<br />(Y.s,no,orunPP/l0!1953-04!02!1954 Donna R. Voyek Wife
<br />
<br />15. ~::'~a~ OF DI~~:~::I:~ t8.. ;M;~~R'S=~~med ---..l:b_LI~~NSE NO _'.. ~:;;~~;aY;~ ),; 0 0 6
<br />CllC,emation U ~nlombmenl 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />o Removal 00111., (Specily) Central Nebraska Cremation Service, Gibbon, Nebraska
<br />
<br />___.____u__ ''',.
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Str..t, City or Town, State)
<br />Kleine Funeral Home, 3213 W North Front
<br />
<br />PART I. Entar Ihallhali1QJe.y~..disaase5, In/u,l.s, or eompllc.llons..that diroctly cau.ad tha dealh, DO NOT anter termlnal.v.nl. such as cardlec arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset 10 death
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dlseBse or condition resulting
<br />In d..th)
<br />
<br />(a) (.....,.., <Y-:-r"' .<2/1
<br />DUE TO, OR AS A CONSEQUENC~ OF:
<br />
<br />/.J~e-J!
<br />
<br />, /'
<br />~{ ~( ."c.'~CL'1
<br />
<br />----?
<br />_,.:> /P."J'......rl.:'1.":'/f
<br />.. ....,,,,..
<br />on.ello deatll
<br />
<br />S.quentl.lly list oonditions, it (b)
<br />any, foadlng 10 Ih.oausellstad DUE TO, OR AS A CONSEQUENCE OF:
<br />on line a.
<br />Entorth. UNDERLYING CAUSE
<br />(dls.... or injury th.t Inlll.t.d (c)
<br />tlle.v.ntaresultlng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />lAST
<br />
<br />onsello dealh
<br />
<br />ongello death
<br />
<br />(d)
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS.Condillons contributing 10 Iho dealh but nol rasulllng in Ih. underlying causa glv.n In PART L
<br />
<br />20, IF FEMALE:
<br />o Not pragnant wllhin past year
<br />o Pragnanl al time 01 daalh
<br />o Nol pregnant, bul pregnant wllllln 42 days of dealll
<br />o Nol pragnant, but p'egnanl43 days 10 1 year before death
<br />o Unknown If pragnant within Ih~. past year
<br />
<br />21a, MANNER OF DEATH
<br />)i<l-Natural 0 Homicide
<br />
<br />o AcoidentO P.ndlng Invesligation
<br />
<br />U Suicide 0 Could nor ba d.l.rmlned
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passeng.r
<br />
<br />o Pedaslrlan
<br />
<br />o OIller (Specify)
<br />
<br />19. WAS MEDICAL EXAMIN~R
<br />OR CORONER CONTACTED?
<br />o YES "it NO
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES
<br />
<br />~O
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />22a. DATE OF INJURY IMo" Dey, Yr.)
<br />
<br />22b. TIME OF INJURY
<br />
<br />.---L. ~--~...--:------
<br />22c. PLACE OF INJURY.Alllome, farm, str..t, faotory, olliea building, construction sil., .Ic, (Specify)
<br />
<br />o YES
<br />
<br />o NO
<br />
<br />m
<br />
<br />o YES 1I NO
<br />
<br />
<br />nd.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO,
<br />
<br />CITYrrOWN
<br />
<br />STPJE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEAT. ~1..rO' 7.' Y;~
<br /><'-'" I
<br />I, ..<" Oil
<br />.... _._ _n"._"n_..
<br />23b, DATE SIGNED. (M , Day, Y.r, /
<br />< "::>'''S 0 (;0
<br />
<br />23d. To the best of my know Ie ge, death occurred at the lime, dale and place
<br />and dualO Ihe cau~(s) .Iated. (Signatu,e and Till.)...
<br />
<br />/ --1,''7,,-/
<br />
<br />25. DID TOBACCO USE C6NtRIBUTE to THE DEATH!
<br />{.
<br />I!;;fYES 0 NO. ...0 PROBABLY 0 UNKNOWN W YES ..)!(No
<br />-----nNMiE, TIT,E ANO'ADPRESSPF CERTIFIER, (PHI'SICIMi, CORO~'$.PH\SiCW~ OR CPUNTY ATtQIlNEY) (Tywor-frin!)., d
<br />Goraon v. rtrnlceK M.U., IL~ N CllSLer, Grana s~an,
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />
<br />...Hj
<br />.cuz
<br />'2g!~
<br />H~~
<br />H~~
<br />"z::>
<br />.coo
<br />t2a:u
<br />o~
<br />00
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo, Day, Yr.)
<br />
<br />24d. TIM~ PRONOUNCED DEAD
<br />m
<br />
<br />
<br />24a. On Ihe basis of examination and/or Investigation, In my opinion death occurred at
<br />the lima, dal. and place and due 10 Ih. causa(s) slatod, (Slgnelure and Tilla)'"
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION B~~N CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />~?t.Appllcable If 2.~a Is NO 0 Y~S 0 NO
<br />
<br />NE,
<br />
<br />68803
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />J.
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo, Day, Yr.)
<br />OCT Z 2006
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