|
- STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA4Z�AI1iD SERVICES, 1T CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE$F.��IS�yQ�P14�2,T��NT.OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F�R �F! �fL �ECOa3 'SJ�, f ,�
<br />a�� f � � ',� ,. � ,� ` ,7 � � , -
<br />DATE OF ISSUANCE '
<br />° � /E,J ���"?7�
<br />o����� � 0�. 1 0 5 4 7 2 ��� $� sx�°� � RE�rs�'�` `'
<br />�1OV y .. ��arrr���r�-���►�TH�N�' :"
<br />LINCOLN, NEBRASKA ` ' ' �VP�I,�EftU�`CES ,' " �'
<br />, �: e� `' ' ' "r
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER�I��ES;� ��� , � tl° �� �� �
<br />CE TIFIC TE O DEAT ,"� ��° �'•- ..� tia' '��p�'�1.�2;. ,
<br />�. oECEO�rswadee (�s. midme, �esc, surr�� asoc �; � � ' p ���� ���YtY�I -r
<br />� Donald Ray Mason Male `' � x � =•C�etobe� 18, 2�08 _
<br />. 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ba. ADE-Last Birthday Bb. UNOER 7 YEAR Bc. UNDER 1 DAY . & DATE OF B1RTH (AEO., Day, Yr.) � •
<br />�Yra.) MOB. DAYS HOURS ALINB:
<br />lowa City, lowa 70 June 4,1938 •
<br />�� 7. SOCIAL SECURITY NUMBER 8e. PLACE OF DEATH
<br />507-42-9780 HOSPITAL: Q InpatleM Q�F ,F.R' Q Nuraing HomeILTC � Hosplee FacWty
<br />Bb. FACILITY-NAME pi irot Instldrtio�, give street emi nwnber) ❑ ERlOutpetleM � Deeedent's Home
<br />pi . .❑.DOA - - - - - _ QOtliaKBPectfYl-.._. . _ -- �-� _ _- - - - - - -_
<br />0 1018 Kennedy Drive - - -
<br />J Bc. CITY OR TOWN OF DEATH (Includa Zip Cade) 8d. COUN7Y OF DEATH
<br />Grand Island 68801 Hall
<br />�� 9a. RESIDENC&BTATE 9b. COUNTY 8c. CnY OR TOWN
<br />�, Nebraska Hall Grand Island
<br />�p ��,�� 9d STREET AND NUA76ER 8e. APT. NO. 9L ZIP CODE 8g. INSIDE C17Y UAAITS
<br />�' 1018 Kennedy Drive 68801 � Yea � No
<br />� � 70a INARITAL STATUS AT TIME OF DEATH � Martied ❑ Naver Merrted tOb. NAME OF SPOUSE (flrat, dllddie, Last, S�rtilx) H wHe, give meiden nama .
<br />p mamea, w,c seParecea Q �nnaowaa Q Di�o.cea p unk�m,xn Doris Vodicka
<br />�� N. FATHER'SNAME (Flrst, f M�ddle, Les; Sutfbt) 12 d101'HER'&NAWE (Flret, IYUddle, Matden Sumeme) '
<br />E
<br />� Ra mond D Stoo s Ma M Smith
<br />m 13. EVER IN U.& ARCAED WRCESI(�he detee oT aervice HYea. 14a MFORMANT-NAME 14b. RE1A770NSHIP TO DECEDENT
<br />H
<br />�ves, No, or unk.� Yes 02/23/1956-02/22/1962 Doris Mason
<br />76. METHOD OF DISPOSITION 18a EMBALMERS1611�ATUR j� /�
<br />�suriel ODonmlon .'= � L{-✓ e � // �(f cV
<br />p��� p��� '
<br />�Removal .�Other(epeeRY� ��18d CEME7ERY, CREd1ATORY OR O li LOCA770N F
<br />Grand Island City Cemetery
<br />17a FUNERAL HOAAE NAd1E AND dWLINO ADDRESS (Street, City or Town, State)
<br />; All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH See instrw
<br />��. 1& PART L Ertterthe ehaln oleva� . tlisoeses, �nputes, m compliaatlons-that AUeeNY rauesA Ure deffih. 00 NOT eMer term
<br />resaireM�Y arrest. m reMiiatet �r�etion without ehmHng ttre etlology. DO NOTABBHEVIATE Eoter oNy one catree on a
<br />IAAMEDIATE CAUSE:
<br />IMMEDWTE CAUSE (Flnai . . . .
<br />'d��■���^�"^g e� cardiopulmonary arrest
<br />lo d0atli)
<br />DUE TO, OR AS A CONSEQUENCE OF: �
<br />Saquantlalry Iiat conrIIdon�, U b)
<br />eny, leadin9 m�e cause Iisted
<br />on Iine a DUB TO, OR AS A CONSEQUENCE OF:
<br />' EMar the UNOERLYINO CAUSE �)
<br />(�sease ot injury that INtlated
<br />tfre erents resul8ng In death) DUE T0, OR A9 A CONSEQUENCE OF:
<br />LAST
<br />78b. LtCENSE NO.
<br />�� � �
<br />CIiY/TOWN
<br />Grand Island
<br />78c. DATE (AEa, Dey, Yr.)
<br />October 22, 2008
<br />STATE
<br />Nebraska
<br />176. Zlp C
<br />ssso�
<br />and
<br />neceaea'Y•
<br />� o�reet W death
<br />�
<br />� immediate
<br />onsetto death
<br />�
<br />�
<br />oneetro aeatl,
<br />�
<br />� '
<br />I onset W death
<br />�
<br />19. WA8 mEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� YE3 ��NO
<br />0
<br />d)
<br />1& PART p. OTHER SIGNIFlCANT CONDITIONS-CondiBona conMbudng W the death but not resuitlng In tlie underiyi� cause given in PART L
<br />�� ZO. IF FEMALE: Z1a dWNNER OF DEATH 21b. IF TRANSPORTATION INJURY 21a WA9 AN AUTOPSY PERFORMED9
<br />F ❑ Notpregnant wtthin past year �] Netural ❑ Homlcide ❑ DriverlOperaMr ❑ YES � NO
<br />� ❑ Pregnarrt et time of death . ❑ AccideM ❑ Pending IrneadB�on ❑ Paeaen9er �d, yyERE AUTOPSY FlNDIN6S AVAILABLE
<br />, �❑ Not pregnent, but pregnaM wifhin 42 days ot death ❑ 8uiclde ❑ CoWd m! be detemdned ❑ Pedestrian TO COMPLETE CAUSE OF DEATH?
<br />� ❑ Not pregnant, but Pre9�'� �� 1 year before death ❑ Other (SP�HY) ❑ YES (� NO
<br />� QUnlmown If pregnant wlfhin the pest year
<br />m
<br />O.
<br />O 22a. �ATE OF INJURY (Mo., Dey, Yr.) 22b. TId7E OF INJURY 22c. PLACE OF INJURY-At home, fartn, etreet, tacWry, oftice bWlrDng, eonstructlon aite, ete. (Speclfy)
<br />U
<br />0 22d. INJURY AT WORK? 22e. DESCRIBE H�W INJURY OCCURRED
<br />F" ❑ YE8 ❑ NO -
<br />TLL LOCATION OF INdURY - STREET & NUdIBER, APT. NO. CITY/TOWN.
<br />$TpTE- ZIP CODE
<br />23a DATE OF DEATH (dAo., Day, Yr.) 24e. DATE SIGNED (Mo., Day, Yr.) � 24b. TIME OF DEATH
<br />�� a�� October, 28,_ 200$ 1:0 a m
<br />��y,, � 236. DATE SIGNED (Mo., Day, Yr.) 23c. TIAAE OF DEATH ���� 24c. PRONOUNCED DEAD (610., Oay, YrJ 24d TIAAE PRONOUNCED Dcen
<br />E�o m E y�a o October l.g 2��8 • d m
<br />� � T3d. To the best ot my Imowledge, death occurred at the tlme. date mM place $ � 24e. On the basls ot examinafi B�on, in my optnion death occurted
<br />a c arM due to the cause(s) atated. (Signature and Title) a O o ac fne nme, dam e m me cauae(s) smeea (s�en�sure ana Tine)
<br />� � � o� Deputy Hal l
<br />�o
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a HAS OROAN OR TISSUE DONATION BEEN CONSIDEREDI 28b. WAS CONSENT GRANTED9 _
<br />❑ YES O. b0 ❑ PROBABLY [� UNKNOWN ❑ YES � NO Not Appltcebte It 28a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRE88 OF CER7IFlER (PHYSICUW, CORONER'S PHYSICIAN OR C011NTY ATTORNEn (Type or PrIM)
<br />Aaron J. Kunz, De ut Hall Count Attorne 23I . Loc s
<br />28a. RE6ISTRAR'S SIONATURE 28b. DATE FlLED BY REa13TRAR (Mo.. Dey. Yr.)
<br />P OCT � 0 2008
<br />0
<br />
|