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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTNw~I~ "tk1ClM~N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASPG9 piE~R,TML~I~T OF HEALTH AND
<br />MUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ~V~7i)1~1%REC© b5' ,;
<br />„~°)r,~.
<br />DATE OF ISSUANCE ,~~/~~ w '~~
<br />03/23/2009 2 0 0 9 0 5 7 3 3 Q~S~ST,4~'lT{.$'TAxE ftEGISTR,~R
<br />DE~tR71W~I~ITa dF`'FI~4LT&t AN!]
<br />LINCOLN, NEBRASKA HUMAN SERI/I~ES- : '
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SHRVIC~S,` ~~lr ~~.~ ,. _ ~'._.'' ,~ ~"' 0$ OOSSS
<br />CERTIFICATE OF DEATH ~o ' , '
<br /> 1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX ~- 3. DATE OF DEATH (Ma., Day, Yr.)
<br /> Doris Maria Voorhees Female June 29, 2008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY B. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> St. Paul, Nebraska 89 June 13, 1919
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 506-26-8525 HOSPITAL ^ Inpatient OTHER ®Nursing HomelLTG ^ HoaplCa Facility
<br /> 8b. FACILITY-NAME (If not Institution, glue street and number) ^ ER/Outpatient ©pacedant's Noma
<br />
<br />v Wedgewood. Care Center ^ pOA ^ Other (SpecHy)
<br /> 8c. CrrY DR TOWN OF DEATH (Include Zlp Code) 8d. COUNTY OF DEATH
<br />a Grand Island 68803 Hall
<br /> 9a. RESIpENCESTATE eb, COUNTY 9c. CITY OR TOWN
<br />~ Nebraska Hall Alda
<br />~ 9d. STREET AND NUMBER e. APT. NO. 8f. ZIP CODE 9q. INSIDE CITY LIMItS
<br /> 45 Venus 6$$10 ®YES ^ NO
<br />
<br /> 19a. MARITAL STATUS AT TIME OF DEATH ^ Married ^ Navar Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name
<br />!E
<br />w ©Married, but separated ®Wldowed ^ Divorced ^ Unknown Qryal VOOrhee3
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 72. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />~ Ellis Klinginsmith Gertrude Kasson
<br />
<br />°~
<br />E 13. EVER IN U.S. ARMED FORGES? Give dates of service If Yas. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />~ (Yea, No, or unk.) No Randy Voorhees Son
<br />gr 15. METWOD OF DISPOSITION 18a. EMBALMER.SIGNATURE 18b. LICENSE NO. 18e. DATE (Mo Day, Yr.)
<br />~ ®euriai ^ ponatlon Timeree Andreasen 1390 Jul
<br />3
<br />2008
<br /> y
<br />,
<br /> ^ Cremation ^ Entpmhment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! tOWN STATE
<br /> ^ Removal ^ otner (specify)
<br /> Elmwood Cemetery St. Paul Nebraska
<br /> 17a. FUNERAL HOME NAME ANp MAILING ADDRESS (Street City or Town, State) 17b. tip Code
<br /> Jacobsen-Greenway Funeral Home, 411 O Street, PO Box 112, 5t. Paul, Nebraska 68873
<br /> ea Instructipns and exam les
<br /> te. PART 1. Enter the chain of eveMa-•dlwawa, Injuries, or compllcatlona-that dlroctly cauwd the death. Dp NpT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> reeplYatory arrost, ar ventricular flbrlllation without showing the etiology. DO NOT ABBREVIATE. Enter only one rauw on a Ilns. Add addl[lonal lines If negssary.
<br /> IMMEDU\TE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) End Stage Dementia ;Months
<br /> dlaasw or condlticn reautting
<br /> in deatnj DUE TO, OR AS A CDNSE4UENCE OF: onset to death
<br /> Sequentially lint conditions, If b) Alzheimers :Years
<br /> any, leading to the cauw listed
<br /> on Ilne a. DUE Tp, pR AS A GONSE4UENCE OF: ; onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (diwaw or Injury that Inttlatad
<br /> the events resulting In death) DUE TO, OR AS A GONSE4UEWCE pF: onset to death
<br /> LASr dl
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS•Conditlons contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Hip Fracture, MRSA Septic Hip, Atrial Fibrillation OR CORONER CONTACTED?
<br /> ^YES ®NO
<br />~
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />~ ©Not pregnant within past year ®Naturel ^ Homicide ^ Ddverlpperetor ^ YES ® Np
<br />U ^ Pregnant at time aT death ©Accident ^ Pending Inveetipagon ^ Passenger
<br /> ^ Not pregnant, nut pregnant within 4z days of death
<br />^ Suicide ^ Could not bs determined ^ Pedaatdan Y1 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />^ Not pregnant, but pregnant 47 days to 1 year beforo death
<br />^ Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br /> ^ Unknown If pregnant within the past year ©YE5 ^ NO
<br />~'
<br />E 22a. DATE OF INJURY (MO., Day, Yr.) 226. TIME QF INJURY 22C. PLACE OF INJURY-At home, farm, Street. factory, OHICa bUllding, COnat1'UCtIOn site, atC. (Specify)
<br />v Not Applicable
<br />~' 22d. INJURY A7 WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />^ YE5 ^ NO not applicable
<br /> 22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.Np. CITYITDWN STATE ZIP CODE
<br /> NA,
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />~ ~ June 29, 2008 -- ~
<br />~~ 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> } Y 23b. DATE SIGNED (Mo., bay, Yr.) 23c. TIME OF DEATH ~ ~ 24c. PRONOUNCEp pEAp (Ma., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~ a $ Jul 2, 2008 07:35 AM r
<br />E d a ~
<br /> e° D 3d. To the best Of my knowledge, death occurred at the time, date and platy
<br />
<br />)
<br />e
<br />W
<br />~
<br />Pie. On the baste of examinatl0n and/or investigation, In my OplnlOn death occurred at
<br /> and due to the wuwjs
<br />stated. (Signature and THle) Q p the time, date and place and due to the cauwia) stated. (Signature and Title)
<br /> ~ Chad Vieth, MD ~ $ o
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE pEATH? 28a. HAS ORGAN OR TISSUE ppNATION BEEN CANSIDERED7 26b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Applicable K 26a IS Np ^YES ^ Np
<br /> ND ype or rant
<br /> Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 284. DATE FILED BY REGISTRAR (Mo., pay, Yr.)
<br /> July 3, 2008
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