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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIRES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />DEC 17 2007
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT'S -NAME (First,
<br />William
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />La Mirada, California
<br />7. SOCIAL SECURITY NUMBER
<br />506 -94 -5785
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />Saint Francis Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />313 E. 9th
<br />10a. MARITAL STATUS AT TIME OF DEATH O Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name.
<br />❑ Married, but separated ❑ Widowed X Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First,
<br />William
<br />Middle, Lest, Suffix)
<br />A. Roach Sr.
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT -NAME
<br />Connie Cronin
<br />(Yes, no, or unk.) No
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />]Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chanel 3005 South Locust Street , Grand Island, NE
<br />18. PART I. Enter the chain of eventfl -- diseases, injuries, or complications - -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />(Assessor condition resulting
<br />in death)
<br />Sequentially Iistconditione, if
<br />any, leading lathe cause listed
<br />on line a.
<br />EntertheUNDERLYING CAUSE
<br />(disease or injury that Initiated
<br />theevents resulting in death)
<br />LAS!
<br />(a)
<br />(b)
<br />(c)
<br />(tn
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />225. DATE OF INJURY (Mu., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />fa -g -o'i
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23d. To the beat of my k
<br />28a. REGISTRAR'S SIGNATURE
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICESFINANCE,P DSUPPOF
<br />CERTIFICATE OF DEATH
<br />la- -o
<br />Middle,
<br />A.
<br />9b. COUNTY
<br />Hall
<br />16a. EMBALM R- SIGNATURE
<br />201307011
<br />Last,
<br />Roach
<br />16d. CEMETERY, CREMATORY 0 OTHER LOCATION
<br />Central Nebr. Cremation Servic Gibbon
<br />YP0VA) s roAJ
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Ff f PAg -ro 2 EAJA -c Sy/v4/i4 Al 4-
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />. DUE TO, OR AS A CONSEQUENCE OF:
<br />Ac5/I, 71ill /
<br />22b. TIME OF INJURY
<br />m
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21a. MANNER OF DEATH
<br />XNatural ❑ Homicide
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT, NO. CRYfTOWN
<br />ledge, death occurred at the time, data and place
<br />and due to the cpGse(s) stated. ($iggaturg and iJ )
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />44
<br />❑ Accident Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />23c. TIME OF DEATH
<br />Suffix)
<br />Jr.
<br />5b. UNDER 1 YEAR
<br />9c. CITY ORTOWN
<br />Grand Island
<br />TANLE .$. COOPER
<br />ASSISTANT kEGISTk4R
<br />HEALTRANb HUMAN .SERVICE
<br />9e. APT. NO
<br />16b. LICENSE NO.
<br />1092
<br />2. SEX.
<br />Male
<br />5c. UNDER 1 DAY
<br />8a. PLACE OF DEATH
<br />HOSPITAL: X Inpatient PTHEB ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ C04 ❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />CITY / TOWN
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />91. ZIP CODE
<br />68801
<br />12. MOTHER'S -NAME (First,
<br />Rosemary
<br />Middle,
<br />Maiden Surname)
<br />Roesler
<br />21 b. IFTRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />O Pedestrian
<br />❑ Other (Specify)
<br />3. DATEOF DEATH (Mo., Day, Yr.)
<br />December 8, 2007
<br />16c. DATE (Mo., Day, Yr. )
<br />Dec 12, 2007
<br />onset to death
<br />onset to death
<br />onset to death
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES LINO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />25. DIDTOBACCO USE CONTRIBUTETOTHE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES i;;PealQ ❑ PROBABLY ❑ UNKNOWN ❑ YES g[ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />David R. Colan MD 729 N. Custer AV, Grand Island, NE 68803
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />33361
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 15,1963
<br />9g. INSIDE CITY LIMITS
<br />2 YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Sister
<br />STATE
<br />NE
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />.V / 141
<br />aYfkf
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES la NO
<br />24b.TIME OF DEATH
<br />ZIP CODE
<br />m
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On the basis of examination axdlor Investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES X NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />DEC 1 4 211n7
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