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<br /> � STATE�F NEgRASFCA-DEPARTMENT QF HEALTH AND HUMAN SERVIC��:r1N:AN�F.,e;ND=SUPPQRT
<br /> GERTIF��ATE DF DEATH � - � , � "��,�.�;�;�
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<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.}
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<br /> ; :�::a���: Grand I s land Hall
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<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
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<br /> �""�``�` �nT�sley L. Sandquist Jeanie James
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<br /> ��;:;�:�� �8. 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
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<br /> any,leadi�g to the cause fisted - �
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<br /> �nter#��UNi]�R�YfNG CAUS� . �
<br /> �disease vr i�jury t�at initiated �c} � ��.�� ���� �
<br /> the events resu�ting i�deatf�] �
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<br /> ` aR CORQNE�C�N7��ED?
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<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?
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<br /> ':.';:�e:' Cl Unknvwn ifi pregnant wit�in ft�e past year ❑ YES ❑N�
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<br /> �:a'' 22a.�ATE�F Ii�JURY M�.,❑av,Yr. ?? Ti,n� ,�F , ,_._ �..__._____�..�.._
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<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}'�
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<br /> S�I�T GRANT�D.
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<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
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