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STATE OF NEBRASKA
<br />WHE'N f HIS COPY CAftRIES THF RAISED SEAL OF THE NFBRASKA DEPARTMENT OF HEALTH qNp NUMAIW SERVICES, IT CERTIFIES
<br />THE BEt�QGV TO B� A TRUE COPY O�' 7"HE ORIGINAL K�CQRD pN FILE WITH THE NE824SK,4 Q$F'��� D� li�ALTH AND
<br />HL7MAN SERVICES, VITA'L RECORDS OFFICE, WHICH IS ThIE LEGAL DEPOSITORY FOR VbTAL ' ��; �
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<br />DATEOFISSUANC� Fr , r ��. . r �
<br />09/10/2010 Sran�`�v � �QbpEr� � '
<br />2 U 1 � 0 9 S 17 Assr�r`�►.� ,�r,aTe��rsr�w� -" . r;, :
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<br />LINCOLN. NEBRASKA HUNh4l���I�,�.� �-�� -'? ;
<br />STATE OF NEBRASKA - DEPARTMENT OF W�ALTH AND HUMAN SERVI� � 1MW " �
<br />- �v � �. .�>7'0`�02505
<br />4.erci iri�,�►i G ur uCW►i n ��. �.
<br />7. DECEDENT'S•NAME (Flrst, Mlddle, La;t, $ufflx) 2, SEX .' # i � 9: bPDE4T . ,,,�lay, Yr.)
<br />Rud Mitchell Pokorne Male �. JS�epteraib�[`�, 2!7"(0
<br />4. CITY AWD STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRThI Sa. AGE - Last Birthday b. UNDER 1 YEAR sc. UNDER DAY �, DqTE p� 91RTH o., Day, Yr.)
<br />(Y�.) MQ3. DAYS HpURS MINS.
<br />Gibbon, Nebraska 87 December 2, 1922
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATN
<br />soa-i a-aosa PI A� Inpatient OTHER � Nursinq lbmslLTC � Hosplce Facility
<br />°�, �. . FI�CRffY-NAME (H not Inatltutlon, giva aheet and number) Q EWUuqntkr�t ❑ DecsdariCs Fbme Y_
<br />� Grand Island Veterans Home 17 �A ❑ Other (Specly)
<br />� 8c. CITY OR TOWN OF DEATW pnclude Zlp Code) ed. COUNTY OF DEATFi
<br />c Grand Island 688p3 Hall
<br />� J 9a. RESIdENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />� 9d. STREET ANb NUM6ER e. APT. NO. 8f. ZIP CODE 9p. INSIDE CITY LIMITS
<br />� 1621 W. $t0118 P2rk 6$$Q1 � YES ❑ NO
<br />. t0a. MARITAL STATUS AT TIME OF DEATH � hAartlad �] Nevar M�rrlQd 106. NAME OF $ppUBE (�Irst, Mlddle, Last, Sufnx) M wlTa, plva malden name
<br />!E ❑ Marrled, but separated ❑ Wldqwad ❑ Divorcad ❑ Unkrwwn Dqris M Shupp
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<br />� 11. FATHER'8-NAME (Plrsy Mlddla, Last, Sufnx) 12. MOTHER'S-NAME (First, Middle, Maldan Swnsme)
<br />� Jaseph F Pokomey Clara J Schuller
<br />�' 13. HVER IN U.S. ARMED FORCES? 6iva datas ot sarvica If Yes. 14a. INFORMANT-NAME t4b. RE4ATIONSNIP TO ��CEDENT
<br />� (Yea, No, or unk.) Yes 03/26/1943-03/16/1946 Nan Nelsqn Daughter
<br />� 15. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURH 78b. LICENSE N0. 78c, ppTE (Mo., �ay, Yr.)
<br />� � BuHal ❑ Donatlon
<br />' p92 September 7, 2010
<br />Patricia
<br />. urran
<br />❑ Crematlon ❑ Entombment qgd CSMET�RY,.CF�AkA* '
<br />Tii�N - - ..,.,. ; CF7PJT�� ,, STATE
<br />� R ��� r r...; .,. „ .,, :.w:.w, r. ,. �.:x.,,...... .. . ... . . ....: ..... . . �
<br />��- �° Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />' y �" 1 a. PUNERAL HOME NAMH AND MAILINO ADDRESS (Straat, City or Town, 3fata) 17b. Zip Coda
<br />Curran Funeral Chapei, 3005 S. I.ocust St., Grand Island, Nebraska 6$$01
<br />TH ee instruc ions and exam es
<br />+e. PAR7 I. Emar the chafn otevents• •diaea�a, �n)uriee, or compticationMtnat mroc�ry cauard the tlrath. op Nor �Mar u�minai awnta such as cardiac arroat, ; APPROXIMATE INTERVAL
<br />reiplYatOry BrYast, Or wnfYlCUlar fl6dllatlon wlthout rhowinp tha rtlolopy. DO NOT ABBREVIATE. Enqr pnly Ons CaUaB On d Ilne. Add apAklOnal IIMi li naC06sary.
<br />IMMEDIATE CAUSE: ; ornat to death
<br />n�w��ou,re c�us� iF�nri .. a) Pneumonia _ �� 717ays
<br />.
<br />,
<br />; �..:., �,,.,,,ve,,,a,rn,rwro�rno; ;
<br />,
<br />In daath) � Dll� 70 OR AS A CONSEQUENGE OF: ; orl8at to death
<br />Srqurntlalty Ilat candttlona, N b) Vascular DemenGa, 5tage 6 : Years
<br />any, kadinp ta the caYq Il�ad
<br />on Nne a. pUE Tp, QR A$ A CONSEQUENCE OF: ; onsat to death
<br />Enterths 11NpER�VING CAUSE �)
<br />(OINaN O� InJury that In111aGd
<br />ehe e�enes resuinnq in aerm� pUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />usT d)
<br />19. PART II.OTNER SffiNIFIGANT CONDITIONS�Conditipns contri6uting tp the death but not resulting in the undarlying causa givan In PART I. 19. WAS MEpIC/AL EXqAAINER
<br />� _. �- m'Nqr� BrAall Cell Carcinoma Of Left Lung; Sleep Apnea. Art CpRUNeR CONTACTED� -
<br />_ . . . ❑ Y�3 � NO
<br />�
<br />LL 0. IF FEMALE: 2/a. MANNER OF DEATH 21h. IF 7RANSPpRTAT10N INJl1R 2'L�. Wq3 AN AUTpP3Y PERFpRMEpT
<br />F- [] Na prepnant wnnm pp� yaar � Notura� � HOmIGId� Q pHvsr/Opsraror '---
<br />U � PI6(�Ilim lt nrlq OT (liatll � p�IMnt � PYndlnp InvrAipatlon � Pat6Bnp0r � Y �`� � NO
<br />Q Not propnaM, but prepnaM witnin 42 aaya oT daatn $�icidr Couid not bs dsterminad ❑ Pedastrian 21d. WHRE AUTOPSY FINDINGS AVAILA6L
<br />� � Nol pnqnant, 6ut propniM 47 ddyi t0 1 yBi� DofOrB dlith � � � p��� �g TO COMPLETE CALISE OF DEA7H9
<br />YE$ NO
<br />� Unknown If propndnt wlthln the pa6t year 0 ❑
<br />� 2Ra. DqTE pF INJURY (Mo., Day, YrJ 22b. TIME OF INJURY 22c. pLACE pF INJURY•At homa, Tarm, atreet, factory, oTflce bullding, constructlon aita, atc. (Specify)
<br />�
<br />� 22d. INJURY AT WORK9 22e. OESCRIBE HOW INJURY OCCURRE�
<br />O
<br />F' ❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMB�R, APT.NO. GITYITGWN STATE ZIP CODE
<br />23a. pATE OF DEATH (Mo., day, Yr.) � 24a. DATE $IGNED (MO., Pay, Yr.) 24b. TIME QF pEATH
<br />� W September 2, 209� _ . :,._.:.. . ._ .. _. ._ ._, _ ,. � _.. � - _
<br />,. �" ('Mo•, Cay, "Yr) 23c. T1ME QP DEATH - � �� 24c. PRONOUMCEq pEAU (MO., Day. Vr. 2id. 71ME PRONOUNC�D DEAD
<br />. 5e tember 7, 2010 p8:Q7 AM `�
<br />�� ]d. To tha 6eat aT my knowledpa, dealh occurrsd al ihs dms, dats and place $��� pM. On tha Wtl� of rxaminatbn and/or Invwtlyatlen, In my opinlan dwth accurced at
<br />B� and dua fo thr cauae�s) slrisd. (Siqnatun and Tkh) $� U tha tims, daM and place and dua to t1ro csuaa(a) abtad. (Siqnature and Tnle)
<br />Gene L. Wyse, DO � a
<br />28. DI� TQBACCQ USE CONTRIBUTE TO TIiE DEATH7 28a. NAS OR(3AN OR TISSUE DONATION BEEN CONSIDERED7 286. WAS CON8ENT GRANTED7
<br />Q YES � NO ❑ BROBABLY ❑ UNKMOWN ❑ YES � NO Not Appllcable N Zea is NO ❑ YES ❑ NO
<br />. R I , pe or ArH
<br />Gene L. Wyse, DO, 2300 West Capital Avenue, Grend Island, Netiraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �_ 28b. UATE FILEO BY REGISTRAR (Mo., Day, Yr.)
<br />September
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