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PART l.�r�fer f�e chain af events--diseases�in�rries or.com I�catiarts--that direcfly caused th�death.D��IOT er�t�rtermir�al e�ents s�ch as cardiac arresi, ��APPR�K]MATE iNTEFiVA� <br /> ^�i�,��"''r;; -�F : J : �' <br /> �.....w <br /> 3T:+-�^�S�" <br /> ���r�: respirafory arcest,or veniricular fibri[iaTian witf�out shawing the etialagy.�O Na i AB8Fi�VIATE Er►ter oniy one cause ot�a line.Rdd additional lines iF necessary. � <br /> :�z���;;;; <br /> r�..,..: <br /> �Y'�'�'y 1 <br /> `��^�' -�lM.iVfEp1A�ECA�ISE:. <br /> �:,,r..,�� <br /> �":s'`�' orsser ta deat}z <br /> �:��=:�'�- A�u�te 0��-Codone i�t��z�atian i imm�d.�a�� <br /> ��k ;� , i <br /> .,�: <br /> =��i,L,�: EIVIME�IA�CAl15E�Ft72� {�}_ _r�►n U n n►.r,•, <br /> �r'-�i t , <br /> °��{��'< dseaseorcor�di�ian resUlti� Q(��TO,�R A5 A C�NS�piJ�NCE��: <br /> T�Y���� � ar�s�t to death <br /> :���:: in deatY�} , � <br /> , �:,�,;�'�� � <br /> �'�~�7�� �� � <br /> 'z�"� 5equen#�aliy Erst�or�d'it'inns,it ` <br /> ;i��-�.�: Pr�scripton pain �3ller us� , on �z7a <br /> Fl�..i� <br /> :a�"-�''•'�'� SFljf:I���ETt�t0�I"E�CSUS���S�£� � � <br /> ,��`'r���� DL]E TD,QR A5 A CdNS�QUENCE��: - <br /> ��a<;:�� an line a. � or�set ta deatt� <br /> "'�'�� f <br /> y;�,x.� E�tertheUNOERLYING CAUS�- <br /> ���:��,,,: <br /> ���x �disease or injury that initiated ��� i <br /> ��.y-::::. i <br /> :��_:�:.: <br /> ��µ�� theevents resuitingin death} ❑��TQ,QR AS A GDI�S�QUENCE�F: <br /> �"�`���. l.AST ❑nsef ta deat� <br /> i{;�.;;'7�{�y' � <br /> �:G��„y�` rd1 - i <br /> �Y: u L 1 3 <br /> ��h.',�x..'A:: i. <br /> 11'��'l��. ' . <br /> '•�'��'�'`' �g.PART�1.OTHER SiGN1FI�RiVT C�NQlT1aNS-Condiii�ns contributing ta the death�ut t�ot resuiting ir�the�r�der�yir�g rause given in�ART 1. .VITAS M��1GAL EXAIVi]lV�R <br /> ��.��. <br /> "�`�;�::: �9 <br /> ;�;�- <br /> :;=�� <br /> _� <br /> ���'� ❑�i CDR�NER CaNTAGTEQ? <br /> ��:� <br /> ���-�� V �+ �I/'� <br /> kppp����.....ii' � i�V � ]VL <br /> �J��� <br /> ; 'r�?�� �0.�F��MA�E: �a.MANN��i aF DLATH 2�h.1FT�Ai�S��RTATION f I�JUFiY��c.VYAS AN ALIT�FSY PERFQRMEO? <br /> �:��� <br /> ��'�"'rr ❑Nol re n � y <br /> �'F,;ri; � g ant wiifiis� ast ear ❑Naturaf ❑Hom'icide �€7riverlOperator <br /> '���" � Y�S ❑N� <br /> ��;� ❑�re nant at time of death -�- C�Passenger <br /> n�v;�. � ❑Acciden ending fnv�stigation <br /> T�ti��'?r`; �Pedestrian <br /> '-�'�:=� ❑Not pregnar�f.but�rea�aniwith�n 4�ciays af deat!z ���.�rV��s�r�i����Sw�Flid�f{�G5 AVAlLABL�T� <br /> �-�s�=��� �.1 S�i�ide <br /> n:;;...:.;k C�Gou[d not be determinad <br /> ���'•�'�t 0 Nt�t re n ❑Other S ecif <br /> y��:;: p g a�i,but pregnant 43 days fv�year be�nr�death � � y� C�MPLET�CAL7S�OF DFAT�-1? <br /> .,r...., <br /> u�:n <br /> �J'"'� CI Unlcr�awr�if pregnant w"ithin the past year ��� <br /> , ,.�ts.� � Y�S <br /> yt.�r",}r�';•:r. <br /> • ��yr'� 2�a.DAT�Q�ENJURY�Mo.,Day,Yr.} 22h:TINiE'�F Ii�JL]�Y ?�c.PL,4G��F[NJURY At home,fa�m,street,tactory,affice bui[dir�g,cor�structian site,etc.�Specify} <br /> , �;��.�,`� <br /> ;y...���r <br /> y:r:k��ti; F eb ru.ar 1� 2��9 �Ta�.ka����' �om.� <br /> i�r�'i�-ir. <br /> ` ;„��"`�{: 22d.1�i,]�IRYATVIJORK? 22e.DESCRiB�H�W ll�,l:l]RY aGCURRED � � <br /> :rv.x <br /> .��f�. <br /> • .�;��`�: �YES �NO <br /> � =,��:�� Stag�ed brea��.i�ng <br /> :�.:;,,��:: <br /> SL':b^-Ui���ti . . <br /> ,,!_,�xr�. ��f.1 Lri��iV��v�il+�.�ii�''1�-."7!t'i��T�c iY�lf�GCi'�",F��i f��. {���Q�N <br /> . -K.�'r,'r"�:' x� <br /> } =�:;:�; , STATE �I�CDDE <br /> �� 3111 ��es�t Col�e e N�braska 6g$�3 <br /> ;��:�;:� ��9?� Grand Is1a�.d <br /> ::� ,: <br /> �r``"`'� 23a.�A7�OF�7�ATH��io.,Day,Yr-] �4a.DAT�59G1���(Mq:,�ay,Yr.} 4�_TIME�F a�RTI� <br /> ��`��w z z�- <br /> t=, �Q T Q� <br /> . ��F;�r���� �_._ ��¢ e b r u a r �5 ��4 9 B����en io.o o � & � 3 6 <br /> �=�,�..�:;;�cn 23h.DATE S[GNED Ma:,❑a Y� � 23�.T�ME�F D�A�H ��� ` . <br /> -�;;:;.�_�� a��� { Y� 3 �} ��c.PRON�UNC�o��Ap M Y � <br /> �.,.m,:;,.a=7- �,� { v.,Qa,Yr. 4d.TIME PR�N�E]iVC�D DEAD <br /> �;�;t�:�?�:� a �n�¢� 1�� 2 Q Q 7 [J.3 V m <br /> ��:��:;,�; � z m ���-� February . <br /> ,},......, <br /> •�-�..,�,.: o �D <br /> k.•.:... <br /> �a��`::�•'� `�� 23�_Tfl the�est ofi m knqwled e death occurred af fhe time,date and lace"� �u�i�o . <br /> � ��-��� �� �' �} P �4e.�n basis o�examinatian andlor ir�vesti ation,in m o inion death vccurred at <br /> �`�'�'�< �� and due t�t�e�ause�s3 stated.(5ig�ature and Tit1e)� �z� 9 Y P <br /> ;���:;,;�� . Q p a e i� e,date ar�d�1 d due tQ tt�e cause[s}stated_�Signature and Titie}'� <br /> r`';:.�;:;�_ ,Q g...�C V <br /> �':� D L <br /> _��?::� " � eputy� Hall Caunt� At arne� <br /> ---���:W;� , <br /> y�:r:�,µ-'�5.Dl�T08ACC0 LSS�CDNTR�BL�TETOTHE aEATH? Ba.HAS DRGAN OR TISS�iE D��A N C�NSID�Fi �E�,WA5 G�NSEf�T GRRNT��� <br /> :r:�:� <br /> ���'==� ❑YE5 Ll I�D ❑PROSABLY �,1 UNKN�`1IIN ❑ YES I�C�O �[ot Ap�lica�le���fia is�VD a YE5 ❑ �E❑ <br /> �'�} ���r�= <br /> �-_��'-;�: �7.I�AME,TfTLE ANO A�]QR�SS�F C�RTIFiER�PHYS[C�AI�,G�RDNE�3'S PHYSlC1Ahi DR C�UI�TY a'TTORtV�Y}�Type ar Print� <br /> = Qarbara �unn De ut Ha�� Caunt �ttorn� ��31 S. Locust Street, Grand Is�and, NE �8 �l <br /> �Sa.REGESTRAR'S 5[GNATURE �8�.DATE F9L,E17 BY R�GISTRA�{Mo:,❑ay,Yr.} ' <br /> • �� �•�� <br />