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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARtMENT OF H�t,L.,'�#
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE AfEB�
<br />Ht/MAN SERVICES, VITAL RECOROS OFF7CE, WHICH IS THE LEC,AL DEPOSITORY FOAf �"',�
<br />- : �1''w- Q
<br />DATE OF 75SUANCE
<br />.�_;, ;
<br />;:�_:�'
<br />� �.,,,� � t n>�ar
<br />�a<,�:.,� ����� ��,.
<br />� �,'% r •�•
<br />�,��' 'y�y ,�'"'
<br />, �.t� ,n, ��
<br />�'��1 �,-= x 10 03733
<br />OF D�ATH (MO., Day, Yr.)
<br />�2�28�ZO,o 2Q1100928 - ta,- T -
<br />���
<br />LINCOLN, NEBRASKA f�ll��• J µ
<br />� � •. r�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER�Ii E'�,.''• �Q F
<br />CERTIFICATE OF DEATH �� t S� �'''•
<br />DECEDENTS•NAME (First, Middle, Lasq 8utflx) 2. SEX sl
<br />,' �� T • -,
<br />Winston Dana Morse Male
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • I.ast Birthday . UNDER 1 YEAR Sc. UNDER 1 DAY 8.
<br />lY►s•) MOS. DAYS HOURS MINS.
<br />Saline Countv. Nebraska
<br />7. 1932
<br />SOCIAL SECURITY NUMBER Sa, PLACE OF DEATH
<br />508-34-9256 HOS I P A�1 ❑ InpaUent OTHER � Nursioy Home/LTC � Hospke Facility
<br />. FACILYfY-NAME (If not instidrtba, give sVaet and numbe� � ER/OutpatleM ❑ DecedeM's Home
<br />Wedgewood Care Center ❑ �► ❑ �(sne�rl
<br />. CIIY OR TOWN OF OEATH pnclude Zip Code) Bd. CWNTY OF DEATH
<br />Grand Island 68803 Hall
<br />. RESIDENCESTATE 9b. COUNTY 8e. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />. STREET AND NUMBER e. APT. NO. 9f. ZIP CODE 8g. INSIDE CITY LIhNT$
<br />118 East 17th St. 68801 � Y� ❑►�
<br />a. MARITAL STATUS AT TfME OF DEATH � AAartted ❑ Never MaRted 10b. NAME OF SPOUSE (Ftrst, Mtddb, last, Sufflz) lf wlFe, give maMan �me
<br />❑ Marrisd but separated ❑ wiaowed ❑ o�vorcea ❑ UnknoMm Donna L Ulrich
<br />. FATHER'S�NAME (First, Middla, I.ast, Sufflx) 12. MOTHER'S-NAME (Flrst, Middle, Maiden Swname)
<br />Dana Morse Gladys Edzards
<br />. EVER IN U.S. ARMED FORCES? GWe dates of service if Yes. 74a. INfORMANT•NAME 14b. RELATIONSHIP TO DECED@NT
<br />nes, No, or unk.) Yes 12/09/1952-12/08/1954 Donna L Morse W ife
<br />. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 18b. LICENSE NO. 18c. DATE (MO., Day, Yr.)
<br />Q eur�a� ❑ Donatlon Chris McCoy 1191 December 18, 2010
<br />❑ Crematbn ❑ Entombment �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (SpeeHy)
<br />Westlawn Memwial Park Cemetery Grand Island Nebraska
<br />a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stats) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />9. PART 6 EMe� the chain Meventr 41eea»s, injurlea, or campifcrtbnythat dirocNy pusad ths dsath. DO N07 e�Merbrmlml ew�rts such.as caMiac srrort
<br />respintory amsl, or veMricular Bbrllladon wkhoul ahowinp tha etiobpy. DO NOT ABBREVIATE. EMer ony one causa on a Ilne. AdA additlonal Iinsa If naeesaary.
<br />iMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Fiml � a) Pfl@U11101118
<br />aiaeaae or co�widon resun�ao
<br />In deaM)
<br />sequemiaiy �ist condiNOns. N
<br />eoy, iaaaxre to uw c+use i�saa
<br />on Ifna a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Recurrent Adenocarcinoma Of The Breast With Pulmonary Metastasis
<br />EMar tMe UNDERIYING CAUBE C)
<br />(dlaease or InJury tM1M Initlatsd
<br />ths avenu resWtinp In tlead�� DUE TO, OR AS A CONSEQUENCE OF:
<br />� d)
<br />3. PART II.OTHER SIGNIFICANT CONDITIONS�Condidons coMrlbuting to the death but i
<br />Diabetes Mellitus Type II, Hypertension, Hyperlipidemia, Obstructive Sleep Apnea
<br />I. IF FEMALE: 27a. MANNER OF DEATH
<br />� Not prepnant wkhin paM year � Natunl � Homicide
<br />� PrepnaM M tlme M deaM � IlccideM � Pe�Mln9 InvesUgation
<br />� NOt prapnaM, but prepnaM within 42 days Ot death � �
<br />� NM prepnaM, but prepnaM 4S tlaya to t year before death �$�� ❑ Could not bs deNrtnined
<br />� Unknown If P�'eYnaM wkhM ths past year .
<br />ta. DATE OF INJURY (Mo., Day, Yr.) 22b. 71ME OF INJURY 22c, PLACE OF IAIJURY•At M
<br />INJURY AT WORK? I22e. DESCRIBE HOW INJURY OCCURRED
<br />� YES ❑ NO
<br />LOCATION OF INJURY • STREE'f & Nt1MBER, APT.NO. CITY/TOWN
<br />STATE
<br />ZIp CODE
<br />2Sa. DATE OF DEATH (Mo., Day, Yr.) 24s. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />� December 12, 2010 � �
<br />�� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIAAE OF DEATH ��� Y 24c. PRONOUNCED UEAD (Mo., Day, Yr. 24d. TlAIE ARONOIRrCED DEAI
<br />�-+ December 27, 2010 12:13 AM °<�
<br />�
<br />�� M. To Me best ot my knovNStlpe, tleath oxurtetl at the tfine, date antl place � �� 2qa. On the basls of examMatlon andlor InvesHpaGOn, M my opinlon deaM occurted at
<br />a am1 dus !o the auaa�i) Wted.131pnature and Titk) E � the time, tlate and plaa amf dw to the aup(a) rtated. (Sipnatwe aa0 Titls)
<br />� Jay C. Anderson, MD ~ � �
<br />.,,J YES � NO �J PROBABLY �J UNKNOWN � YES � NO
<br />I ,
<br />lay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />REGISTRAR'S SIGNATURE � _.,,� � � _
<br />APPROXfMA7E1NTERVAt
<br />onset to death
<br />Days
<br />onsetto death
<br />Months
<br />or�sat W death
<br />onsetW death
<br />In the unde�lying cause gNen In PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED4
<br />❑ YES Q NO
<br />Ib. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� Drlver/Operator
<br />❑ vES p NO
<br />� Pasanper .
<br />� Paeaulan 27d. WERE AUTOPSY FlNDINGS AVAILA
<br />� Other (8peciy) TO COMPLETE CAUSE OF DFATH7
<br />❑ ves ❑ No
<br />farm, street, factory, office buildin9, coraVUCtfon sRe, etc. (8pacify)
<br />Not Applicable H 28a Is NO rl YES LJ NO
<br />28b. DATE FILED BY RECaISTRAR (Mo, Day, Yr.)
<br />December 27, 2010
<br />D�c�rriber i2, 20i0
<br />DATE OF BIRTH {Ma, Day, Yr.)
<br />
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