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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH-AND-HU`W VkVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA A>*2 kr 0,0 HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQRT4,(~p/y d
<br />DATE OF ISSUANCE
<br />04/11/2011 STAItILEY 5 r CQ9PER "
<br />201207495 AS8IS7'~INT~$T1AtE~fR~I~TRAR''
<br />DEPARTMENT-OF HEALTH AND
<br />LINCOLN, NEBRASKA HU(If*So3mICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIG`ES fl`t►
<br />CERTIFICATE OF DEATH R ,tJ;, '1'L..01170
<br />1. DECEDENTS-NAME (Fbst, Middle, Last, Suffix)
<br />2. SEX
<br />3. DATE OF DEATH (Mo, Day, Yr.)
<br />Richard Thomas Strickland
<br />Male
<br />_March 22, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />S. DATE OF BIRTH (Mo, Day, Yr.)
<br />(Yrs.)
<br />MOS.
<br />DAYS
<br />HOU
<br />Ho
<br />t Springs, South Dakota
<br />61
<br />n
<br />
<br />December 29, 1949
<br />7.96- IAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />503-58-4638
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />Bb. FACILITY-NAME (H not Institution, give street and number)
<br />❑ ER/outpatlent ❑ Decedenrs Home
<br />Saint Francis Medical Center
<br />❑ DOA ❑ Other (specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />8d. COUNTY OF DEATH
<br />5
<br />Grand Island 68803
<br />Hall
<br />I
<br />Ga. RESIDENCE-STATE
<br />6b. COUNTY
<br />BO. CITY OR TOWN
<br />lu
<br />Nebraska
<br />Hall
<br />Grand Island
<br />0
<br />8d. STREET AND NUMBER
<br />e. APT. NO.
<br />Of. ZIP CODE
<br />89. INSIDE CITY LIMITS
<br />1220 N. Custer Ave
<br />IS
<br />1 68803
<br />® YES ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ®Married ❑ Never Married
<br />0b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden fens
<br />11
<br />❑ Married, but separated ❑ Widowed ❑ DIvoreed ❑ Unknown
<br />Inez Tomlinson
<br />NIna
<br />m
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First Middle, Malden Surname)
<br />Richard Thomas Strickland Margaret Anna Maria Lindner
<br />
<br />E
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />14a. INFORMANT-NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />8
<br />(Yea, No, or unit.) No
<br />Nina Inez Strickland
<br />Wife
<br />2
<br />15. METHOD OF DISPOSITION
<br />16a. EMBALMER-SIGNATURE
<br />6b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />12
<br />❑ Burial ❑ Donation
<br />Not Embalmed
<br />T
<br />March 24, 2011
<br />® Cremation ❑ Entombment
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, state)
<br />17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />68801
<br />CAUSE OF DEATH (See Instructions and exam es
<br />18. PART I. Enterthe chain of evena-41aeases, InJurls% or compnratione-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, I APPROXIMATE INTERVAL
<br />respiratory arrest, or vanutcular fibrination without showing the etiology. DO NOT ABBREVIATE. Enter only one muse on a fine. Add additional Wrea If rreeeaeary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />IMMEDIATE CAUSE (Final a) Cardiac Arrest ; Minutes
<br />disease or condition resulting
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />setpmntteny ltet conditions, if b)Traumatic Brain Injury ; 2 Days
<br />any. leading to the muse Hated
<br />on fine a DUE TO, OR AS A CONSEQUENCE OF: 0 onset to death
<br />Enter the UNDERLYING CAUSE c) Motor Vehicle Accident E 2 Days
<br />Was, a or inJurythat Initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LAST d) I
<br />I
<br />18. PART (.OTHER SIGNIFICANT CONDITIONS-ContlMons contributing to the death but not resulting In the underlying cause given In PART 1.
<br />18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />W
<br />LL
<br />0.
<br />IF FEMALE:
<br />21a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21a WAS AN AUTOPSY PERFORMED?
<br />❑ Not pregnant within past year
<br />❑ Natural ❑ Homicide
<br />® Drivedoperetar
<br />® YES NO
<br />❑
<br />L
<br />❑ Pregnant at time of death
<br />® Accident ❑ Pending Inv gation
<br />❑ Passenger
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ ❑
<br />Suicide Could fiat be determined
<br />❑
<br />Pedestrian
<br />21d. WERE AUTOPSY
<br />AVAILABLE
<br />S
<br />O
<br />❑ Not pregnant. but Pregnant 43 days to 1 year before death
<br />❑ Dam (Spe fy)
<br />E CAU
<br />E
<br />F DEAT?
<br />Unknown H pregnant within the past year
<br />® YES ❑ NO
<br />E
<br />22a. DATE OF INJURY (Mo, Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />8
<br />March 21, 2011
<br />12:04 PM
<br />Oklahoma Ave W. And S. Greenwich Streets
<br />.9
<br />Ed. INJURY AT WORK?
<br />229. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />YES ® NO
<br />The decedent was driving a motorcycle, wearing a helmet, when he was struck by another car.
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />Intersection Of Oklahoma Ave & Greenwich St., Grand Island Nebraska 68801
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.s
<br />91 April 8, 2011 08:37 PM
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />k
<br />Z
<br />}
<br />< ¢ March 22, 2011 08:37 PM
<br />8' O . To the best of my knowledge, death occurred at the time, date and place
<br />$ O 24e. On the basis of examination andfor Irrvestlgation, In my opinion death occurred at
<br />and due to the muse(s) stated. (Signature and Title)
<br />8
<br />and place and due to the muse(s) stated. (Signature and Title)
<br />time, date
<br />the
<br />`
<br />VerM Hall Deputy County Attomey
<br />aas,
<br />is Gail
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ® YES ❑ NO Not Applcable if 26a Is NO ❑ YES ® NO
<br />27. NAME, TITLE D CERTIFIER (PHYSICIAN, R COUNTY EY) (Type or Print)
<br />Gall VerMaas, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo, Day, Yr.)
<br />April 11, 2011
<br />
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