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<br />20090297 6 STATE OF NEBRASKA-OEPARTMENTOFHEALTHAND HUMAN SERVICES FINANC EANDSUPPORT
<br />CERTIFICATE OF DEATH
<br />
<br />32~849
<br />
<br />
<br />1. DECEDENT'S-NAME (Flr.t,
<br />Fredrick
<br />
<br />Mlddl.,
<br />Ri le
<br />
<br />La.t,
<br />Graves
<br />
<br />Suffl.)
<br />
<br />2. SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo., Dav, Vr.)
<br />March 20, 2007
<br />
<br />Omaha, Nebraska
<br />
<br />5a. AGE.La.t Blrlhdav
<br />(Vr..)
<br />59
<br />
<br />
<br />6. DATE OF BIRTH (Mo., Oav, Vr.)
<br />
<br />4. CITV AND STATE OR TERRITORV, OR FOREIGN COUNTRV OF BIRTH
<br />
<br />October 11, 1947
<br />
<br />7. SOCiAL SECURITY NUMBER
<br />505-58-8761
<br />
<br />Sa. PLACE OF DEATH
<br />1lQ5fJJAI.'
<br />
<br />lb lnpallanl
<br />
<br />onm a NUl'8lngHomelLTC aHoaplo.Faollllv
<br />
<br />6b. FACILlTV.NAME (If not Instllullon, glo. slr..1 Bnd numbBr)
<br />
<br />a ERlOutpall.nt
<br />
<br />a Doood.nl's Hom.
<br />
<br />VA Medical Center
<br />60. CITY OR TOWN OF DEATH (InoludB ZIp Cod.)
<br />Omaha 68105
<br />gB. RESIOENCE-8ll1TE Db. COUNTY
<br />
<br />o 00\ 0 OII1er (speclty)
<br />ed. COUNTV OF DEATH
<br />Dou las
<br />
<br />Nebraska
<br />
<br />Hall
<br />
<br />
<br />9<1. STREET AND NUMBER 9/. ZIP CODE
<br />1112 West Anna 68801
<br />lOa. MARITAL STATUS AT TIME OF DEATH Marrl.d 0 Nover MBrrled 10b. NAME OF SPOUSE (Flr.', Middle, Le.t. Suffi.) II "110, give mald.n nsm..
<br />
<br />gg. INSIDE CITY LIMITS
<br />UVES a NO
<br />
<br />;"'O"IOd, Ii!I.epOrOIBd a widowed ODlooroed Q.I,InknoWT1_.. _ -
<br />.... . _'.. . .. - .. no ..."..
<br />
<br />',\!. FATHER'S.NAME (Flrsl, Mlddl., Le.',
<br />" Frederick Walter Graves
<br />
<br />13; EVER IN U.S. ARMED FORCES? Glo. dSI.s orssrolo.IIV...
<br />
<br />(V,", no, or unk.) Ye
<br />15. METHOD OF DISPOSITION
<br />
<br />Dli Burl.1 0 Don.llon
<br />
<br />Dian1a' '1ft8l't:i'~e"l"eY -
<br />
<br />'.~''lI",.....-,-. .........'.lII'_..'-c~',..
<br />
<br />""-,,,,---,-' ~ - .~"~'" ,-'~:_---
<br />
<br />
<br />Suffl.) 12. MOTHER'S.NAME (Flr.',
<br />Doris. Ripley
<br />
<br />Mlddl., MBlden SurnBme)
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />o Cremellon 0 Enlombm.nl
<br />
<br />CITV /TOWN ,
<br />
<br />160. DATE (Mo., Day, Vr,)
<br />March 26, 2007
<br />
<br />STATE
<br />
<br />16b. LICENSE NO.
<br />/,}.8'y
<br />
<br />o RemooBI 0 OIh.r (Speolfy)
<br />
<br />Ft. McPherson National Cemetery
<br />
<br />17.. FUNEFlAL HOME NAME AND MAILING ADDRESS (Str.el, CItV or Town, St.te)
<br />Livingston Sondermann Funeral Home, 601 N. Webb
<br />
<br />Maxwell
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />on..'1o d.ath
<br />
<br />IMMEDIATE CAUSI! (FInB1
<br />dl_ oroondlllon rnuntng
<br />In .....,)
<br />
<br />(a)
<br />
<br />
<br />failure
<br />
<br />
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />onoOl to death
<br />
<br />Sequonfl.lly 11.1 oondmo"", II
<br />."Y,IBBdlng 10 the 011II" n_
<br />on 'In...
<br />I!n\BrIheUNDERlYlNO CAUSE
<br />(d1_.. or Inlury Ihel Inlll.led
<br />the""",,,"ruuIllngln_)
<br />lASJ'
<br />
<br />~ Metastatic adenocarcinoma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />weeks
<br />on.ello de.th
<br />
<br />~ Pancreatic cancer
<br />DUE TO; OR AS A CONSEQUENCE OF,
<br />
<br />months
<br />
<br />onsat to d.alh
<br />
<br />(eI)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDlTIONS-Condlllon. oontrlbutlng to tha de.lh but nol r.sultlng In Ih. und.rlvlng oaUB. given In PART I.
<br />
<br />Acute renal failure
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />a VES Xl NO
<br />
<br />20. IF FEMALE,
<br />Q Nol pregn.nl within p..t ye.r
<br />o Pr.gnant'l time 0' deeth
<br />a Nol plllgnanl, bUI progn.nt within 42 daYI 01 d..th
<br />o Not pregnenl, bUI plllgn""t 43 dlYll 10 1 V." bololll d.eth
<br />o Unknown Jt pnlgn.ntwlthln tho PBBI y..r
<br />
<br />21a. MANNER OF DEATH
<br />.. NBtur.1 Q Homlold.
<br />
<br />aVES
<br />
<br />>bNO
<br />
<br />CJ Aooldenla Pending Ino.sllg.lIon
<br />o Sulolde CJ Could nol ba dOl.rmln.d
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Driver/Op.r.lor
<br />
<br />o PI..anger
<br />
<br />Q PadBBlrlan
<br />
<br />CJ Olher (Speolly)
<br />
<br />210. WAS AN AUTOPSV PERFORMED?
<br />
<br />21d. WERE AUTOPSVANDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />CJ VES a NO
<br />
<br />CJ VES 0 NO
<br />
<br />
<br />22.. DATE OF INJURY (Mo., DBY, Vr.)
<br />
<br />22b. TIME OF INJURV 220. PLACE OF INJURY.At hom., larm. .Iraat. faolory, offlca building, _.Irucllon .Ua. elo. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221, LOCATION OF INJURV . STREET" NUMBER, APT. NO.
<br />
<br />ClTYITOWN
<br />
<br />smre
<br />
<br />ZIP CODE
<br />
<br />23e. DATE OF DEATH (Mo.. Dey, Vr.)
<br />March 20, 2007
<br />
<br />24a. DATE SIGNED (Mo.. DOV, Vr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />illi
<br />B!~
<br />~8~
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo., Day,Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On Ih. bBSls ole.amlnlllon and/or Ino..llgatlon, In my opinion death occurred .t
<br />Ih.lIm., dal. and pl... and duo to lh. oau.o(.) a..t.d. (Slgnatura and TltlB) T
<br />
<br />26a, HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Applloiible If 26& II NO Xl VES 0 NO
<br />
<br />.68105
<br />
<br />"
<br />
<br />:: -::. .... ~.- .~.( ~ i
<br />. 'f--'~'-"'~___""'. . . ..
<br />
<br />Th{~~i~~s...~;.;'J..1'A.'i.':~.:..'~;~ . ni~i,~.J.a tru... e copy of an original record ori"file with Vital Statistics. Douglas C. ounty
<br />Heal~\~. .W~':~. .'~." ~.~ ,.;lti~ . .... .9tb.. ..Q.., ~ Certified copies must bave a raised seal in the area to the left. Reproductions
<br />of thls~01'~mfi9.atel1l1i:i1pt' legal copies.
<br />'~~.-.., :',r:.r.--;) 'J(\ ';.'>"'~'~'~).'~~:.'
<br />Date Issued: "'"""l"'MAR 2 9 2007
<br />
<br />Registrar:
<br />
<br />/i n c:::-
<br />J!:\c:X....::: - J
<br />
<br />:::::> ----
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