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<br />200803182
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT328310
<br />CERTIFICATE OF DEATH
<br />~.~.- _.'~,... -
<br />
<br />male
<br />
<br />3. DATE OF DEATH (Mo.. Day, Yr.)
<br />October 30,2007
<br />
<br />1. DECEDENT'S.NAME (First,
<br />Wi 11 iam
<br />
<br />Middle,
<br />Edward
<br />
<br />Last,
<br />
<br />Vejvoda
<br />
<br />Sulllx)
<br />
<br />2. SEX
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />58. AQE.L8.1 Blrlhday
<br />(Yt'~1
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5e. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Day, Y'.)
<br />
<br />January 12,1946
<br />
<br />60. PLACE OF DEATH
<br />
<br />1:IQ.Sf1IAI..:
<br />
<br />~ InpaUent
<br />
<br />QlHEB: 0 Nur.lng Hom./LTC 0 Ho.plee Faclllly
<br />
<br />o ER/OutpaU.nt
<br />
<br />o Deeedenl'. Horn.
<br />
<br />J9b.COU;;: 11
<br />
<br />o 001\ 0 Other (Spsclly)
<br />
<br />6d. COUNTY OF DEATH
<br />Do.ugl as
<br />
<br />68105
<br />
<br />
<br />9f. ZIP CODE
<br />
<br />9g. INSIDE CITY LIMITS
<br />~ YES 0 NO
<br />
<br />ttL Doreen Str~et 68803
<br />lOa. MARITAL STATUs AT TIME OF DEATH ~8rr18d 0 Nelle' Married lOb. NAME OF SPOUSE (Flrsl, Middle, La.l, sutllx) U wll., gl1l8 m.lden name.
<br />
<br />o Married, bul .eparated 0 Widowed 0 Dlllore.d 0 Unknown
<br />
<br />Bon ita Morse
<br />
<br />11. FATHER'S-NAME (FI,.I,
<br />
<br />Middle,
<br />
<br />
<br />12. MOTHER's.NAME (FI,.t,
<br />Grace
<br />
<br />Mlddl.,
<br />
<br />Malden Su,n.m.)
<br />
<br />-_._~
<br />
<br />Welch
<br />
<br />13. EVER IN U.S. ARMED FORCES? GI.. dal.. of ..rlllcell y... 148.INFORMANT-NAME
<br />..~~e.,no,orunk.yp" ,_.!JIBI_ ~--_. Bonita Vejvoda J:----
<br />15. METHOD OF DISPOSITION 160. EMBALMER.SIGNATURE _.. ...._ 16b.lICENSE NO.
<br />OBurlel o Donallon Not Ehlbalmed _~___..
<br />t6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />14b. RelATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c, DATE (Mo., Day, Y,.)
<br />11-01-07
<br />
<br />)4 Cremellon 0 Entombment
<br />o R.mo..1 0 Olher (Specify)
<br />
<br />CITY / TOWN
<br />
<br />STATE
<br />
<br />Heafey-Hoffmann-Dworak-Cutler Crematory
<br />-- -,-_.
<br />
<br />Onaha, NE
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (SI,.el, City or Town, Stale)
<br />Curran Funeral Chapel 3005 S. Locust Street
<br />
<br />16. PART I. Enle, Iho mJ,!~..dl.eo'.., In/u,lo., 0' eomplle.llon...thot dl'oelly cau.ed the death. 00 NOT enl.r lermln.I...nt. .ueh.. cardiac arre.t,
<br />'e.plratory arre.t, or lIenl,loulo, lIb,lIIallon wllhoul.howlng Ihe eU~logy. DO NOT ABBREVIATE. Enl.r only on. e.u.. on a line. Add addlllonal line. II n.c....ry.
<br />IMMEDIATE CAUSE:
<br />
<br />on..lto d..th " .......
<br />
<br />IM"'EDIATE CAUSE (Anal
<br />dI_.e or condllloo r..ulltng
<br />In_)
<br />
<br />(a) Respi ratory Fail ure
<br />
<br />I days
<br />I
<br />I on.ello d..th
<br />I
<br />
<br />~ years
<br />
<br />I on.ellO de.th
<br />I
<br />!1.0 years
<br />I
<br />on.etlo dealh
<br />
<br />"
<br />
<br />DUE TO, OR AS A CONsEOUENCE OF:
<br />
<br />SequenU,"y lIol.ondlllono, II (h) 0 s t e omy 1 i tis
<br />ony,leedlng 10 Ihe .'uso "olad DUE TO, OR AS A CONSEQUENCE OF: .-.
<br />online..
<br />Entorlh. UNDERLYING CAUSE
<br />(dt..... or Inlury Ihollolttoled
<br />"'"...,nto....ulllng In dealh)
<br />IABr
<br />
<br />~_ Chron i c Obs tru~t i ve ~U Trfl0rfcl~~_.Dtseil:ee
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />squamous cell cancer
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES Xl NO
<br />
<br />1 B. PART II. OTHER SIGNIFICANT CONDITIONs-Condlllon' conltlbullng 10 Ihe death Itul not r.,ulllnglo Ihe underlying eBU.e gl..n In PART I.
<br />
<br />o Aeeld.nlO P.ndlng Inv..llgallon
<br />o Suicide 0 Could not b. det.rmln.d
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Dri..,/Operalor
<br />
<br />o P....ng.r
<br />
<br />o P.d..tri.n
<br />
<br />o Olher (Speolly)
<br />
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />DYES d:NO
<br />
<br />20. IF FEMALE:
<br />o Not pregn.nl wllhln pa.' yeer
<br />o p,.gnanlalllm. 01 d..th
<br />o Nol pregnant. but pregnant wllhln 42 d.y. 01 d.ath
<br />o Not pr.gn.nl, but p,egn.nt43 d.Vs 10 1 year belore death
<br />o Unknown II pregMnl wllhln th. p..t y..r
<br />
<br />2t a. MANNER OF DEATH
<br />& N.tural 0 Homicide
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />DYES ONO
<br />
<br />
<br />22.. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22e. PLACE OF INJURY-At home, '.rm, .lre.l, tactory, olllce building, eon.truellon .11., etc. (Sp.olly)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY - STREET & NVMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />Sll\TE
<br />
<br />ZIP CODE
<br />
<br />I <"i""),,~,,,..:'
<br />.,.t'" "".
<br />23a. DATEQF~A H. (M~~;~'o~, {,6, ·
<br />.' \. . .,' . '. ,
<br />,9..~_t:9~er30 .2001. <) .
<br />2;lb.. ..... ,'D.-A. fE,siGNED .(M. o. ,..,o"fl.Yr.)" ".' "i. 31. !..TIME.OF. D. EA. nf
<br />f OctoberSv ;~007,;t, ... y '~:.5 ~ 57 p m
<br />
<br />240. DATE SIGNED (Mo., Dey,.Y,.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />!,~i:i
<br />li!~
<br />lIili~!
<br />Bi58
<br />~g;U
<br />811
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo.. Day, Yt.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24.. On the boala ot examlnallon and/or Inv..llgallon, In mv opinion death ooourred at
<br />the lime, date and place .nd du.to Ihe o.u.e(.) Slaled. (Slgnalure .nd Tille) T
<br />
<br />25. DI?Tci~Cco~". E 0 HEoem-tf' "if.} " 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7
<br />
<br />X:l YES:\,[] Ner". [lPRoMBl'( ,.0 NKt{{iWN Xl YES 0 NO .
<br />27. NAME, T.ITLE'Al'iDI\DDRESS OPce"tIFIER .. YSIAN,CORONER'S PHYSICIAN OR COUNTY ATTO~NEY)(Typ. or Prlnl)
<br />Greg6rY'''G..Q,lden'''M~;\.omaha VA Medical Center, 4101 Woolworth Ave. Omaha,NE 68105
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />NoI A.E!,!.leableU 26a I. NO 0 YES 00 NO
<br />
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />OCT 3 'J
<br />
<br />This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County
<br />Health Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions
<br />of this green certificate are not legal copies.
<br />
<br />Date Issued:
<br />
<br />OCT 312007
<br />
<br />Registrar:
<br />
<br />AJ6--J".
<br />
<br />~ .....",tP
<br />OeM'
<br />
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