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����� �� �������� <br /> V�1'�-1rE'N TH1S C�PY�r4 R14lES THE i�AlSED SFAL DF THF IIdEBRA SfG4 HEA LTN A�L7 Ff U�V1�4 N S�R V10E5 ��14����� <br /> S YS T�E'M,lf CF'F�3"IFlES fHF l3FL Q 1N T4 BE�[TRC�E CaPY QF T�E�F�1Gl111A L Fi���i��'�11�FrL�'W�'Tl� . <br /> THE 11fEBRAS,�CA FlEALTH�4N!]F�l'�M�4N SERVIC�E`S 5'YSTFM, VlTAL STi4�"i�Tl��S�C��f��; �lIH«N!S <br /> �NE LEG►�L DFP�]SlT�R Y F4F�VlT�4 t R�'C��4DS. .�: w � ��==_.. ::�. <br /> _ <br /> _ _--_ ... ...... <br /> _ � � <br /> DATE OF,�SSUAN�E , .._: =�_ =:��=: <br /> � �� r' ' � .r . . . ��11��.��.S.�L'���Ef� . <br /> �� �, � ���� � � ��A� S�ST"�fld�ST�4TE�aE`��57"��4� <br /> S <br /> t�`I11�DL N,NFBR�4 SfCAr N�,�4 LT�aI�D J�fU���I:=��F��I-�C�S <br /> � STATE�F NEgRASFCA-DEPARTMENT QF HEALTH AND HUMAN SERVIC��:r1N:AN�F.,e;ND=SUPPQRT <br /> GERTIF��ATE DF DEATH � - � , � "��,�.�;�;� <br />� r �:?;:?pi�;y;�;:�: • ' . . <br /> ; ,,;�,;i,�,;: �.DEC�DENT'S-NAM� (Firsf, Mi�dle, Last, Suffix} �.SE�C 3,DA`fE OF pEATH Mo. ❑a Yr.} <br /> . ,i'i3Fr..' { ' <br /> '""r:�.:�;� t Y <br /> �'=��=�r�;'; �esley Ste�ren Sandqui�t Mar�h lfl Z�Q� <br /> ��i�e���� Male , <br /> ;:;�.. <br /> �:,};..�� <br /> � �'�'z•�°`" 4.C11"Y AND STAT�DR T�ARIT4RY,❑R��i�E1G�!CD�JN�"RY 4F BfRTH 5a.AGE-Last Birthday 5�,UN��f�1 Y�AR 5c.LINa�R�1 DAY 6.DAT�O�Bf RTH �Ma.,❑ay,Yr.} <br /> ::f2R.1{?z�;, . <br /> " :��;�:=i::a Tild en, Neb raska �Yrs.j 5� M�S. DAYS �ao��s Mli�S. �, 1��� <br /> �:�:.=�fF�: Januar� . <br /> �::;;�:.;. <br /> ;,: .; <br /> s.a��i 4:s;t%�� <br /> s'�,;';�'�:; <br /> . .ri,`ti4-; �._....... _.._----------_- 8a.P�AC�OF�EA�'H <br /> ���}.`> H�SPITAL: ❑ [npatient� Q7'F��R: ❑Nursi�g HameILTC ❑Haspice Facility <br /> :i:i', <br /> . � `�'�;';, 8h. FACf�17Y-NAME {if�ot 11�5�f�Llflp�#, give sic�et ar�d n�€m��r) <br /> � � ❑�RlOutpatient �C]e�edenf's Hame <br /> � '�`:=: <br /> a .:_c�:.: Hom�� 71.� Fas� �.�fih �� . <br /> _ �:;:; <br /> �} ;�.=: � ❑ �1 ❑O�her�5�oecifY} <br /> y'�'��`' Sc,C€"fY OR 701�1 <br /> � ;;J:;.� N OF❑EATH�lr�cf�de�rp Cade� 8d.C��NTY D�D�ATH <br /> �-:�;;:;� <br /> ; :�::a���: Grand I s land Hall <br /> a ;;W;:!:' <br /> � ::�;>;;:; <br /> � ::::�;,:�: �a.1��S1DE�lCE-STA7E ��.cauN�r 9c.CITY�R�'�WN <br /> ��. ,. <br /> :,u.;:=, <br /> '=��,,� ;`���;:` Neb raska Hal� �rand I s land <br /> i�: <br /> -:.zs�=�� 9d.STR��TAND NUMB�� 9e.APT.NO 9�.�1P C�DE 9g.INSID�CITY L�M1TS <br /> .;a�:,=-. <br /> ����'� 717 East 13 th <br /> ��-.;� S t. f$8fl 1 � r�s ❑ n�o <br /> � ..�Y�.�`..•.�:: <br /> W <br /> ;;;�;�;�. 1�a.MA�ii�'AL STA7L�5 AT 7fM�QF DEATH �M���;�� ❑��ver Married 10�.NAM���S�'Q�JSE F€rst,MiddlE,�.asf,Sutf�x If wife <br /> :::;�?':;:: � 7 ,give maiden name. <br /> =:�u:;:: <br /> ..w.,,.. <br /> '�3�;��.�� ❑Married,but separated ❑Wi�owed ❑Divarced ❑L#n€cnawr� <br /> �=`���=` N�e lva Umb enhower <br /> :_:o:_:: <br /> ;t�.:. <br /> '-;�i:�: 1 i.FATH�R'S-NAM� ��irst, M�dd�e, �ast, 5uf�ix} 1�.M�T�€ER'S-I�AM� �First, Middle, Maiden 5urname� <br /> �""�``�` �nT�sley L. Sandquist Jeanie James <br /> ,;o.=,�: <br /> �M-�::: <br /> :,:;:��:�: <br /> .;�`�:;f�' 13•EVER IN�1.5.ARM�❑FORCES?Give dates of service if yes. 14a.INFORMAI�T NAME f 4b.RELATIDNSN€P�'Q DEC��ENT <br /> �;�Y�;: �Yes,no,or un�c.3 N� Me lva S andquis t �►�'1f E? <br /> . :-':'_:-;,: �5.METHD��F�1SPOSITfflN 16a.EM M -SfGN lJRE 15b.LIC�NSE NQ. 16c.❑AT� �M�.,❑ay,Y�.� <br /> ,.[; 'J� �Burial ❑DQnation �� <br /> . �� � March 14, Z�4G <br /> �;F ❑Gremation ❑��tom�ment ����C�������,CR�M 4 Y�R 4THER�QCA'�IQN C�TY 1 TDV►!N 57AT� <br /> :;;;: <br /> �'�;: <br /> ❑��mo��� ❑�ther�Specify} ��s t 1.awn Memo r ial P ark. C�m�t ery Grand I s land, NE <br /> �7a.�UNE�iAL HOM�NAM�AND MAILi�VG ADDR�SS {Street,�ity arTawn,State} �7b.zip Code <br /> �`�����3'�;� Apf��. 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PART I.Enter the chain of�,v,ents--diseases,injuries,or compfi�ativns--ti�at directly caUse�the death.D�NOT e�ter termina€�vents such as card'€a�arres#, APPROXfMAT�1�lTERVAL <br /> �::�:-�`'''; I <br /> >'>:-.��.� respiratary arrest,ar ventri�ufar fibrillation witho�rt s�awirrg the etivlogy.�p NQT ABBF��VIA'�E.�nter onfy vne cause an a lir�e.Add additiona!fines i#necessary. � <br /> ��= iF�� <br /> `t�-°� IMMEofR�"�GA�JSE: ��nset to death <br /> �f�� �: I T <br /> - ff�ME�EA��CA�lS��Fina! ��a� �.,r.-��r"�-� C� �"�'�--Q�-� c3L,.t'' � i <br /> ��. �,� � �� ��'�.,..� <br /> dEseaseorcondi#ionresu#ting ���Tp,pR RS A C�iVSEC�[1 NC���: <br /> in deat�� 1 anset to death <br /> ;i � <br /> 5equentia[fy list conditians,if t�� �.��� � f <br /> any,leadi�g to the cause fisted - � <br /> DlJ�T4,�R AS A CQNSEQUENCE��: I vnset tv deat� <br /> ;;; <br /> on Iine a. <br /> �nter#��UNi]�R�YfNG CAUS� . � <br /> �disease vr i�jury t�at initiated �c} � ��.�� ���� � <br /> the events resu�ting i�deatf�] � <br /> �AST <br /> DU�T�,QR AS A C��VS�QU�NCE DF: E ar�set ta dea#h <br /> yi, �d� � . <br /> i <br /> �`;'�i 8.PAF3T If,OTH�R 51GNIFfGANT CQNDiTf�NS-Conditions cantributing ta fhe death hut�of res�lting ir�i�e underlying cause give�in�ART€. 19.WAS M�DICAL�XAMIi��R <br /> ` aR CORQNE�C�N7��ED? <br /> �'�-�-�r�-ti.-�r�-�.� '�"�� '" � <br /> �-�.c�.-u �] -�. C� <br /> v�s ��No <br /> ��::�:'-;. r <br /> 2a.fl�F�MAL�: <br /> ::w::�:; ' 2i a.MANN �DEATH 21 b.IFTRANSPORTA�fON fNJ�€�Y ��c.Vti1AS AN AC�7d�'SY PERF�F�ME�? <br /> `':tiE.;;'". <br /> ���- ❑Nat re nant withir� a#uraf ❑Homic€de ❑Driverl0 era#ar r <br /> '.;F•�; P 9 past year . � <br /> ��': ❑Passer� ❑ YES � <br /> :��W:'; ❑Pregnant a#time af deafh ❑Accident0 Pe�di� g get <br /> �U�= g inves#i atian <br /> '`�"�� ❑Na# re nant,b�t r� nan#within 42 da s ot death � ❑Pe�estrian <br /> ;,:�,: p � P 9 Y ❑Suicide ❑Co��d nat be determined ' �id.W�R�AUT�PSY�IND�NGS AVR1LA8f��70 <br /> `'`�`' ❑Na!pregnant,b�r#�regnant 43 days tv�year before deatl� ❑�ther(SpecifY� <br /> '''�� C�MFLETE CALISE OF D�ATH? <br /> >,a�; <br /> ':.';:�e:' Cl Unknvwn ifi pregnant wit�in ft�e past year ❑ YES ❑N� <br /> �:E:. <br /> �:a'' 22a.�ATE�F Ii�JURY M�.,❑av,Yr. ?? Ti,n� ,�F , ,_._ �..__._____�..�.._ <br /> :U=: � . 3 - �. � JF+=.JL�3Y �2c.PLr���Ur i�#JUFiY At home,farm,s€reet,fa�tary,�#fice building,co�struction sit�,e#c:�Specify} <br /> , �. <br /> �a m <br /> ;:���:� - <br /> :�"''`. 22d.ItJJURYA�'W4RK? 22e.D�SCf�fBE FiQW f€VJUFiYOGC�RR�❑ <br /> []Y�S ❑N� <br /> ��f.L�CRTIQN�F INJl1RY-S�REET&NL#MB�Fi,APT.NQ. C1TYC�flW�V STATE �fl�COD� <br /> . <br /> :`;,,; �z �3a.DAT'��F D�ATH{�30.,❑ay,Yr.� z� 24a.DAT�S1�N�❑�Ma.,Day,Y�.} �4b.3"fM��F qEATF# <br /> ,�a �.��QwQ� aW <br /> -�� �u� m <br /> �� � <br /> ;; �,�- ' .23�.QATE SIGI��q�Mv.,Day,Yr.} ��3c.�IM��F D�A�"H �_� 24c.PR�NQL�NC�D�ER(J(Mv„Day,Yr.) �4d.`fiM�PRON�UNC�Q D�A❑ <br /> Q,_� � <br /> ��,z � ��`� �,;�� (� m ��a� <br /> � ° �° � ���Q m <br /> �� ?�3d.�v t�e�est o#my kr�owledge,deafh occurred at the.t3�r�;da4 a�d pla�e ��= 24e.�n t�e basis o#examinatia�andl�r investigation,it�my apinian death occurred af <br /> and due the cause(s}stated 4Signat�re anct:'�'tl�} v�p the t�me,date and pEacE and due ta tl��cause�sJ sta#�d.{5ignafur�and Ti#le}'� <br /> ~Q ?.. ,� ��U <br /> � � �... - Q '- <br /> U v <br /> �>�.�5.DIDT�BACCO US�COiV�RfBL1TE�'QTHE���7H`� ` 6a.HAS�RGAN flR T1551��f�QNA710�[BE�N C�NSii]�R�D? 6b.WAS G�N � <br /> ��:- <br /> S�I�T GRANT�D. <br /> � � <br /> C�'�ES 0 ND ❑��08ABLY ❑ UN€CNOWI� -� ❑ YES ..n° ' ��,..� <br /> �-�'�"� ��- (�� ot A�p�i�able ifi�5a is NQ ❑YES Li-Np <br /> �T.NRM�,Til'L�AND ADDRESS OF CE��1F{��i�PHY51C1AN,�OR�NER'S PHYS1CfAN fl�i COt}N7Y ATf�RNEY��Type or Prin#} <br /> Kenneth I�, Vettel M.D. �116 �, Faidley ve. , Grand Island,NE. �88p3 <br /> 28a.R�GISTRA�'S SIGNATll�E <br /> �8�.�AT���LEp 8Y�EGlSTRAR{Ma.,aay,Yr.� <br /> � � , � - <br /> ���� ���� ���� . <br />