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- . STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALThl.AN¢l�tJ��11V ��'/�ll�CES, IT_CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE'BR�YSKL����f��lR�M�fII,F Cah' F/FALTH RND
<br />HUMAN SERVICES, V1TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR !fl€AL �2�'�DRDS �>
<br />�� r C? :' � � �� ,
<br />DATE OF ISSUANCE �•_ ��
<br />oti27i2o� 2 2 012 0 2 6 3� ST,�►� �: �p oP�R �= ,;�
<br />A55TS�`�A?1F'F S� �'II �T'17Af� �; �'
<br />C3Els"/dR°�M��11 �� �` �
<br />LINCOLN, NEBRASKA NUI�IAI1lSER�'CES : ����> ' .±'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ';�:,' :�'�� �� fi G�� `��' �•,�'� „g 7 nn�d7
<br />CERTIFICATE OF DEATH - ' € F: `-_:*- "�`"� - """ '-
<br />1. DECEDENTS-NAME (Flrst, Middle, Last, Suftlx) 2. SIX ;�� 3. kTE 0� qEAT,R (Mo, Day, Yr.)
<br />Cherie Lee Sperling Female - �```F'�bruary�, 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREI(iN COUNTRY OF BIRTH Sa. AOE • Lsst BiRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY': 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(1rB•) MOS. DAYS HOURS MINS.
<br />Ord, Nebraska 71 August 16, 1940
<br />7. SOCIAL SECURI7'Y NUMBER 8a. PLACE OF DEATH
<br />505 OSI}�PIT L� � InpaUe�U OTHER ❑ Nursing Home/LTC � Hospiea Fadlily
<br />8b. FACILI7'Y-NAME (Ii not Instfdrtion, gNe atreet and number) � ER/OutpeUant ❑ Decedent's Home
<br />C
<br />� Saint Francis Medical Center ❑ ooa ❑ Other (Speclfy)
<br />� 8c. CIIY OR TOWN OF DEATH prrclude Zip Code) Bd. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL ed. STREET AND NUMBER 9e. ApT. NO. 8f. ZIP CODE 9g. INSIDE CITY UMITS
<br />� 4050 Craig Drive 68803 ��s ❑ No
<br />� 10a. h7ARRAL STATU3 AT TIME OF DEATH � IAarrled ❑ Nevar Mlartied 10b. NAME.OF SPOUSE (Firat, Middle, Last, Suf(Iz) If wHe, g(ve malden name
<br />€ ❑ n�amea, nuc separeted ❑ vnaowed ❑ onrorcea ❑ unknown Carl Spe�ing
<br />� 11. FATHER'3-NAME (Firat, Middle, Last, Suftiu) 72. MOTHER'3-NAME (Firat, Middle, Matden Sumame)
<br />m Emest Homer Velma Cox
<br />Q ' 13, EVER IN U.S. ARMED FORCES? Give dates of servlce N Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� �rea, No, or unk.) No Carl Sperling Husband
<br />,$ 1S. METHOD OF DISPOSITION 78a. EMBALMERSIGNATURE 78b. UCENSE NO. 18c. DATE (Mo, Oay, Yr.)
<br />F ❑ BuMal ❑ DoreUOn
<br />Not Embalmed February 8, 2012
<br />� Cremadon ❑ EMombment 16d. CEMETERY, CREMATORY OR OTHER IOCATION CITY I TOWN STATE
<br />❑ Remorai ❑ aner (spec�ry� Central Nebraska Crematlon Services Gibbon Nebraska
<br />778. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, Cily or Town, Sfate) 77b. Zip Code
<br />Apfei Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />C US OF DEATH See instructions and exam es
<br />7& PART 4 Fsbsrtheffiatn M evaMS--0�seasea, lnJuriea, or eomp�eatlon�Uiat tlireetly muead Na death. DO NOT aMar mrminat eve�Ae wch es caNiac arrest, : ApPROXIMATE INTERVAL
<br />reapiratory anest, or vemriwlar 6brl0atlon wrtthout showing the edWogy. DO NOT ABBREVIATE Enmr onry o�re cause on a 16re. Add addidonal 14ree H neeeaeary.
<br />IMMEDIATE CAUSE: ; onsat to death
<br />�mx�murecnuse�,�� a)Traumatle Subarachnoid Hemorrhage ; Within 5 Hours
<br />diseesa or condidon resuldng
<br />��'� DUE TO, OR AS A CONSEQUENCE OF: : o�reet to death
<br />s�,roen„o�s�o�areo„s,n b)Blunt Force Trauma : Within 5 Hours
<br />anr. �aaare to nre ca� �a =
<br />�� a DUE TO, OR AS A CONSEQUENCE OF: : o�et to death
<br />EMerUre UNDERLYINO CAUSE �) Motor VehiGe Accident � Within 5 Hours
<br />(aisea� or InJmY fliat Int6ateu
<br />tire aveme reauttlng m deatn) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />� d)
<br />18. PART 11. OTHER SIGNIFlCANT CONDITIONS-CorMklorre conMbuUng to tha death but rrot resulUng In the uruiertying cause given In PART 1. 18. WAS MEDICAL D(AMINER
<br />OR CORONER CONTACTED7
<br />Q , ❑ YES � NO
<br />� 0. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21e. WAS AN AUTOPSY PERFORMED?
<br />� � Not pregnant withln past year � r�,� � Ho�uaaa � u�ao��co. [] res � nto
<br />v 0 aree�M as artre m a�m � n�aaaM � Pendirtg ImestlBadon ❑ a��ee�
<br />� � NM pregnairt, but pregnaM wnhin 42 tlays of deatb euldde CoWd nM be datemd�red � P���" 21d. WERE AUTOPSY FINDINGS AVAIIABLE
<br />❑ ❑ TO COMPLETE CAUSE OF DFATH4
<br />� Not P�B� but PreBnant 49 daye to 1 Yaer beTOre death � Other (Speciry) � ❑ .
<br />� Q Unknown H pragna�rt wlthin tha past year YES NO
<br />°' 22a. DATE OF INJURY (Mo, Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street ��ory, office bullding, cor�sWctlon stte, etc. (Spectty)
<br />E
<br />3 Februa 6, 2012 09:35 AM Intersecdon Of 13th Street And Higway 281.
<br />� 22d. INJURY AT WORK? ?2e. DESCRIBE HOW INJURY OCCURRED
<br />F The decedent was the driver of a vehicle that collided with another vehicle at the intersectlon of 13th Street and hlghway
<br />❑ ves � tvo 281. The decedent was westbound on 13th street. The other veh(cle was southbound on hi 281
<br />22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />Intersection Of 13th Street And Highwa 281, Grand Island Nebraska 68802
<br />23a. DATE OF DEATH (Mo, Day, Yr.) 24a. DATE SIONED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� � ��� February 24, 2012 01:42 PM
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.J 24d. TIME PRONOUNCED DEAD
<br />$� o � 6 a¢ Februa 6, 2012 01:42 PM
<br />To the 6effi M my q�mrledga. death occurted et tha tlrtre� daOe and place �
<br />& 8 see. on the bae�e oi exem�nanon antllor InveaUeadon, ln my opinlon death oaurted at
<br />F am+ aue to ure ca u s e(s� smma. �si¢nature ena nue 1 0 u re a m e� d a o e a n a v� a n a a u e w t n e c a u s a( s� e m c a d. � s i a n e n u a e n a T w e �
<br />'g g s Dave Medlin, Hall Daputy Counry Attomey
<br />25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applipble If 28a Is NO ❑ YES ❑ NO
<br />2. NAME, TIT AND ADDRESS OF CERTIFIER P SI ASS19T , CORO R S H S A (Type or nt)
<br />Dave Medlin, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE �- � 28b. DATE FlLED BY REGISTRAR (Mo„ Day, Yr.)
<br />February 27, 2012
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