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<br /> STATE OF NEBRASKA
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT QF HEALTH A)N H{J 441Q 54RWCE,S, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB10",iq~N7> ''AR, EA4TJ~?,C~~rHH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE WHICH IS THE LEGAL DEPOSITORY FOR' VIZ.AL, RE 4) y,, p
<br /> DATE OF ISSUANCE ° Jp
<br /> ; S xsTanr~x~~'
<br /> 10/29/2009 201000763
<br /> LINCOLN, NEBRASKA 17UM~N11'~,Il(ICS
<br /> STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVlc 3 ' ~ ~ p ~ a ` • t^h 09 02436
<br /> CERTIFICATE OF DEATH ~[.r r "
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX w 1 ` 3. Rq,TE•OF'DEATH (Mo., Day, Yr.)
<br /> Laura Ann Little Female October 20, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE -Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Chicago, Illinois 67 November 11, 1941
<br /> 7, SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 298-36-3974 HOSPITAL ® Inpatient THER ❑ Nursing Home/LTC ❑ Hospice Facility
<br /> Old. FACILITY-NAME (If not institution, give street and number) ER/Outpatlent ❑ Decedent's Home
<br /> K
<br /> 0 Saint Francis Medical Center r ❑ DOA ❑ Other (specify)
<br /> K 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br /> .5 1 Grand Island 68803 Hall
<br /> a 9a. RESIDENCE-STATE 9b. COUNTY 9t:, CITY OR TOWN
<br /> z Nebraska Hall Donlphan
<br /> LL 9d. STREET AND NUMBER 96. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> T 217 Apricot Ln 68832 ❑ YES ® NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH Married
<br /> ~ ® ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br /> ar
<br /> EE ❑ Married, but separated ❑ Widowed []Divorced ❑ Unknown Gary Little
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> Charles Wittkowski Lorraine VonDerAhe
<br /> a 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes, 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> E
<br /> $ (Yes, No, or Unk.) NO Ga Little Husband
<br /> •00 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br /> M ® Burial ❑ Donation
<br /> Patricia R. Curran 1092 October 24, 2009
<br /> ❑ cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br /> [I Removal Other (Specify)
<br /> Cedarview Cemetery Doniphan Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br /> Curran Funeral Chapel, 3005 S. Locust St„ Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH (See instructions an exam es
<br /> 19. PART I. Enter the chain of events--diseases, injuries, or complications-that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, I APPROXIMATE INTERVAL
<br /> respiratory arraat, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) END STAGE CHRONIC OBSTRUCTIVE PULMONARY DISEASE >3 YEARS
<br /> disease or condition resulting
<br /> in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> Sequentially list conditions, If b)
<br /> any, leading to the cause listed
<br /> on line a.
<br /> DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (disease or Injury that initiated
<br /> the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 18. PART It. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death hot not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ❑ YES ® NO
<br /> W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ® Not pregnant within past year ® Natural ❑ Homicide ❑ DriverlOperator ❑ YES ® NO
<br /> U Pregnant at time at death Accident ❑ Pending Investigation ❑ Passenger
<br /> T Not pregnant, but pregnant within 42 days of death El Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> not be determined TO COMPLETE CAUSE OF DEATH?
<br /> Not pregnant, but pregnant 49 pays to 1 year before death 11 Suicide ❑ Could n Other (Specify)
<br />
<br /> Unknown if pregnant within the past year ❑ YES ❑ NO
<br /> E 22a. DATE OF INJURY (Mo,. Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJVRY•At home, farm, street, factory, office building, constr6etion site, etc. (Specify)
<br /> U
<br /> .9 22d. INJURY AT WORK?
<br /> F 22e. DESCRIBE HOW INJURY OCCURRED
<br /> El YES ❑ NO
<br /> 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYrrOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., pay, YrJ 24b. TIME OF DEATH
<br /> .t I October 20, 2009
<br /> } 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br /> g October 26, 2009 02:43 PM z
<br /> a 0 29d. To the best of my knowledge, death occurred at the time, date and place o
<br /> v w 24e. On the basis of examination and/or Investigation, In my opinion death occurred at
<br /> a, and pus to the cause(s) staled. (Signature and Title) 9 1 p the time, date and place and due to the cause(s) stated, (Signature and Title)
<br /> Kenneth Vettel, MD
<br /> 25. DID TOBACCO USE CONTRI13UTE TO THE DEATH? 26a. HA5 ORGAN OR TISSUE OpNgTION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO Not Applicable If 26a is NO
<br /> ❑ YES ❑ NO
<br /> AM TITLE 1 (Type or Print)
<br /> Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> October 27, 2009
<br />
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