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<br />_"'""""""~">!" . _,"~,_:'.'1'V_
<br />
<br />
<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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~.. ~ If ~
<br />
<br />DATE OF ISSUANCE tJ. WV8'"
<br />~"lE '" 3 1 2007 . .. T~tpJ!YS~C;!}OPER
<br />u - ~,' , ASSISTIVI(!lT~rr;f!.E~S1'IjAR
<br />LINCOLN, NEBRASKA HEALTH,MIOHt1MAN siR~S,.
<br />.,',', .. V' ,--\.'- oj '~:, ,;
<br />
<br />'~ 200800685 :.....!:./ ,r'..!p...........:... 1I.' .\i.-'.......~..J.',.......'.'..'~'
<br />,. ~., :.. ~ 't r, s' '~~: : ~~ .~~:, '"
<br />___~_._.,.________._.__.STATE OF NEBRASKA - DEPAR~~~~I~~~~;~N~~U~~~~~VICE~~,N~~~.~...;:upp'S.r11~17
<br />
<br />1. PECEPENT'S.NAME (First. Middl., Last, Sutti,) 2, ~x .,t. ,-..":1. '.~'" ~F1iE ~1MO"pay.Yr,)
<br />Irvin Louis Vodehnal M81,~ 1"':1. , e~' !lO~t.. 11. 2007
<br />
<br />4. CITY ANP STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a, AGE-Last Birthday 5b. UNDER 1 YEAR 5c,UNDER rDAY . .6.. bATE ,OF BIRTH (Mo" Day, Yr,)
<br />(Yrs.) MOS. DAYS HOURS MINS,
<br />Grand Island. Nebraska 76 August 21. 1931
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-28-9701
<br />
<br />8., PLACE OF DEATH
<br />
<br />til:mf!IAl.:
<br />
<br />o Inpatlenl
<br />
<br />0Il:JEB: 0 Nursing HomelLTC 0 Hospice Facilily
<br />
<br />IllI ERlOutpalianl
<br />
<br />o Decedent's Home
<br />
<br />St. Francis Medical Center
<br />
<br />DC(lA.
<br />
<br />o Othar (Spaolfy)
<br />
<br />8c, CITY OR TOWN OF PEATH (Includa Zip Code)
<br />Grand Island. Nebraska
<br />
<br />68803
<br />
<br />8d, COUNTY OF DEATH
<br />Hall
<br />
<br />Hall
<br />
<br />
<br />ga, RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b, COUNTY
<br />
<br />9<1, STREET ANP NUMBER 9t, ZIP CODE
<br />2300 W. Capital Ave. 68803
<br />10a, MARITAL STATUS AT TIME OF DEATH XJ Marriad Cl Naver Married lOb, NAME OF SPOUSE (Firsl, Middle, Last, Suffix) It wlte, give maid.n nam.,
<br />
<br />gg, INSiDE CITY LIMITS
<br />
<br />Xl YES 0 NO
<br />
<br />o Married, but separaled 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Joann
<br />
<br />Stauss
<br />
<br />11, FATHER'S-NAME (First,
<br />
<br />__,_.~_!~!J~,~S t __."
<br />13, EVER IN U.S, ARMED FORCES? Give dale. ot .ervlcell ye., 14a,INFORMANT.NAME
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Sufllx)
<br />
<br />12, MOTHER'S-NAME (First,
<br />Emil
<br />
<br />Middle,
<br />
<br />Maiden Surname}
<br />
<br />(Yes, no, or "nk,)
<br />
<br />Yes
<br />
<br />6-20-49/4-16-5 Joann Vodehnal
<br />
<br />IGNATURE~ h" ~
<br />P-L~ ,. ,,-.--
<br />
<br />18d CEMETERY, CREMATO OTHER LOCATION
<br />
<br />
<br />I 6b. LICENSE NO.
<br />
<br />Puncochar
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />Souse
<br />16c, DATE (Mo., Pay, Yr.)
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />~urial
<br />
<br />o Donation
<br />
<br />__..___112.L
<br />CITY /TOWN
<br />
<br />December...J4
<br />STATE
<br />
<br />2007
<br />
<br />o Cremation
<br />
<br />o Entombmenl
<br />
<br />o Removal 0 Othar (Specity)
<br />
<br />Grand Island City Cemetery. Grand Island. Nebraska
<br />
<br />17., FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, Cily or Town, Stat.)
<br />Livin ston-Sondermann Funeral Home. 601 N. Webb Road
<br />
<br />PART I. Emer the chain...oLeven~.--diseases, Injuries, or compllcations--that directly caused the death, DO NOT enter terminal evenl. such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a linE!. Add additional lines it necessary,
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />
<br />IMMEDIATE CAUSE,
<br />
<br />\)_~~rdi opulmonary arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />
<br />I onsa' to d.ath
<br />I
<br />
<br />It-3D minutes
<br />
<br />Sequ.ntlally lI.t conditionS. It
<br />any, leading to the causa listed
<br />on line I,
<br />Entarthe UNDERLYING CAUSE
<br />(dl..... or Injury th.t Inltlal.d
<br />tho ovente ....ultlng In death)
<br />lA'ir
<br />
<br />K
<br />(b) natural (age)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I onset to death
<br />I-r-
<br />I
<br />I
<br />
<br />onset to death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />
<br />1..._.._,.___'"'
<br />I onsello death
<br />I
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condition. contributing to Ihe d.ath but nol r.sulting in th. und.rlying caus. giv.n in PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />-t';R CORONER CONTACTEP?
<br />
<br />~ YES 0 NO
<br />
<br />(
<br />
<br />_._respj.r.~j;Qry d i ffi cu 1 t
<br />20. IF FEMALE:
<br />o Not pregnant wilhln paSI ye.r
<br />o Pregnant at time of death
<br />o Not pregnanl, but pregnant within 42 days 0' dealh
<br />1:1 Not pregnant, but pregnanl43 day'to 1 year before death
<br />o UliknoVl:'!'l if p.r~grjanl within the p!S1 y,Nr
<br />
<br />21a, MANNER OF DEATH
<br />-\'" ~ Nalural Cl Homicide
<br />
<br />o AccidentO Pending Investigation
<br />
<br />21b.IFTRANSPORTATlON INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />o Prlver/Operator
<br />
<br />o Passenger
<br />
<br />DYES
<br />
<br />Il\l NO
<br />
<br />Cl Suicide 0 Could nol be determined
<br />
<br />o Pedestrian
<br />o Oth.r (Specify)
<br />
<br />21d, WERE AUTOPSY FINPINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />.,. - - ,-
<br />t:f YES 'cXNO
<br />
<br />22e. PATE OF INJURY (Mo., Pay, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY,At home, farm, 'treet, 'aclory, olllce building, construction site, etc, (Speclly)
<br />
<br />m
<br />
<br />22e, PESCRIBE HOW INJURY OCCURREP
<br />
<br />U YES LJ NO
<br />
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STArE
<br />
<br />ZIP CODE
<br />
<br />23a. PATe OF PEATH IMo" Pay, Yr.)
<br />
<br />m
<br />
<br />"'~~
<br />JJ~a::
<br />ilg?~
<br />U<l;~
<br />E."'" Z
<br />8ffi~O
<br />1:z:>
<br />~~8
<br />86
<br />
<br />24a, PATE SIGNEP (Mo" Day, Yr,) 24b, TIME OF DEATH
<br />
<br />~~<;~f!1l>.~"L_~.9_I._gQQL .~~_J.L;~____~~~~_
<br />
<br />240, PRONOUNCED DEAD IMo" Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />>Oecember 11 2007 '>i 11: 48 am
<br />
<br />23b, DATE SIGNED. IMo" Day, Yr,)
<br />
<br />23c, TIME OF DEATH
<br />
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(,) statad. (Signatura and Title) l'
<br />
<br />
<br />o NO
<br />
<br />25. PIP TOBACCO USE CONTRIBUTETOTHE PEATH? 26a. HAS ORGAN OR TISSUE DONATION BE
<br />
<br />lr- 0 YES 0 NO Cl PROBABLY ~ UNKNOWN -\Q YES ~ NO
<br />27,~M~iTLE ~D ~ OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />
<br />Robert J. Cashoili De ut Hall Count Attorne 231 S, Locust Street
<br />
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />Grand Island NE 68801
<br />28b, DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />DEe Z 6 2007
<br />
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