��14�554�
<br /> STATE �F NEBRASKA
<br /> WhI�N TH�S CDPY CARRIES 7`H�E RAISED SEAL DF THE IIfEBRASIG4 pEPARTMENT QF HE�4LTFf Aii1D hIUM�IV 5FR�l1�CES�IT CE1�
<br /> �NE BEL�W TQ BE A TR[l�C�PY QF THE�R�G�NAL RECDRD�N F'�LE WITH THE NEBRASI�4�DEPARTHIENT�3f H�ALTH A1VD
<br /> HUMAN S�'R 1I�CF5, VITAL RE'CaRDS 4FFICE� VIfHICH�5 THF LEGAL DEP�SITQR Y F�R VIT_,
<br /> �-,
<br /> �.�,.
<br /> DATE DF ISSUA IVCE . -"_,.�.
<br /> ..-��,,,,�; �_ _
<br /> �8I��1��14 sT��v�Fy s. co�.pP� � -
<br /> ASS����'Al1�T�TA�R���S7'`�1R
<br /> L�L�P�4�4TM�€1VT�f N��ILTH Al1�D
<br /> LIN��LN, NEBRA5I�A H,�CI�F�4N S�I�,l1���S
<br /> 5TATE QF�1��RA5KA-�EPAFtTMENT Qf HEALTH AN��UMAN SL�V�EE� '� ' ��.
<br /> C�f�T�F���TE�F D�ATH �. '���3D�'
<br /> 1.�EC�DENTS-NAME �First, i�iddla, La�t, 5�xj �.5E7� 3.DATE[3F vEATH�M�.,o�y,Yr.y
<br /> Je De�n Hufins Mafe � � �vbe.r��5,�a1�
<br /> 4.�ITY AN�STATE qR TER�RlT�3RY,QR F�RElGN C�]UNTRY OF SIRTH ,AGE-Last Birthd�y .UNDE�t 1 YEAR S�.Uf�Q�E'�R 1 D�Y ,�,�Ai'��.B�1�TH�Mo.,Dey,Yr.y
<br /> ��=f M�3�S. DAYS H�i#JRS AA� ..
<br /> BV��+��T I�e�raska �7 `' VG'L.�Gm�f GJ� �9�fL
<br /> 7.�OCU#L SE�URtT1f NUMBER Sa.PLACE�F D�ATH
<br /> 505-5�-574s � �In�ttlent QTHER ❑Nur�iny Nome1LTG []Hoapica Faci�ity
<br /> 8b.FAC�LITIf-NAME[I#nat Ins#itu�lon,yira atres#and nun�er�
<br /> ❑E�autp�tiant ��n�'a Nome
<br /> �
<br /> � 1?�1 Al�en C�urt ❑�A ❑D�er{3pe�ffyj
<br /> -� . _ _ - _ - - - - �
<br /> .GtTY DR TDWlV�F DEATH{Ineiude�ip Cc�de) �a.couN�►oF o�►a,ni
<br /> � Grand fsland 68$03 Hali
<br /> � �.RESIDENCE-STATE 8b.C[3UMTY Sc.CITY pR TQWN
<br /> z Nebra�ka Haf! Grand Island
<br /> � 9d.STF�EET AND NUIi�BER .APT.AIQ. 9f.TJP��E 9�g.iNSiDE CITY LIIIAITS
<br /> �, 172�Al�en�ourt fi8$�3 �vEs [] n�v
<br /> 1Da,MARlTAL STATU�AT TIME�F DEATH�]Marri�d []Na�►sr Mar�ried 10b,NAME�F SPOUSE�First, MiddEe,. Last, Sufl�x�If wi�e�gi��rna�den name
<br /> �
<br /> � ❑Married,bu#aeparated ❑VIAdoPwed �Dirvrced ❑Linknawn
<br /> �
<br /> 71.FATHER`�-NAME �Firs#, Middie, Laa#, �x) 1�.M�THER'S-NHME �Firs#, Il��ddte� Ma3iden Surname�
<br /> _
<br /> Edward Hulinsky �athsryn Bruha
<br /> a` 13.EVER IN l].S.A�MEO FQRCES?Gi►re datea of servica if Y�. 14a INFdRI�ANT-�NAME 't4b.RELIRTI�NSF�P T�DECEDENT
<br /> E
<br /> � �Yes,Wo,or Unk.j[VO Scott Hulins SOr1
<br /> � 15.METH�DF DI3R�ITiaN 1Ba�MBdq�MER-SICI�ATUF�E '�ih:L�CENSE Ni']. f5c.DATE 4Mo.,Day,Yr.]
<br /> � ❑�ai ❑non�o� N�#Emba�med �ctob�r 25,2U'�0
<br /> �Crarrwfian ❑Entarr�ment ,��.�������AT�RY�3R aT'HER LDCATI�N CfTY 1 TDWI�I STATE
<br /> ❑R��a1 ��thar 4���Yy
<br /> Vl�stlawn Memvriat Park�rema�ary Grand Isi�nd Nebraska
<br /> 17a,FUHERAL HQI�E NAME AND ll�►A�LING A�E�S�5tr+est,Ciiy pr Town,5#at�j 'i7b.Z�p Code
<br /> Livingstan-�vndermann Fun�r�l Ham�,fifl� N.VlFebb Raad,Grand Island,Nebraska �8803
<br /> A �ns�ct�o��an exam le�
<br /> 1i.PART I.Er�ter th��in of eder�#s-�1i�s�inju�s�vr conepFic�ar��t dir+�ctly caw�d ths�,OD 11fflT��bnnina�areMs s�ch�cardiac�mest� � APPR4XIMA'fE 1NTERVAL
<br /> �P��f►+��,or wntricuiu#ibrNleltivn rrit�no�rt shvrvir�ths�iola9y.1�NqT ABB�YIA7E.E�r oniy an�causa vn a�ir�e.Add add�fon�d lin�if�c�sry. �
<br /> IMMEatATg CAllSE: ; ons�t to de�th
<br /> �Ev��cAusE tFi�� �i Heart Attack � Immedi��e
<br /> -- diseasa�r cvnd�tlan!'�u�tin9 _ 1
<br /> in dsathy � � -Y ,- -
<br /> DIJE TC),QIi A5 A C�NSEQUEiiiGE QF: f onset to dsath
<br /> sequerrt�liy ilst canditians,i� b� �
<br /> ■ny,lva�din9 to the�r.�I�sted � 1
<br /> or�li�a�, �
<br /> DUE T�,4R AS A C,QNSEQUENCE DF: � �g��a�m
<br /> E�er t#�e UNUERLYtNCi CAUSE �� �
<br /> [d�seass or ir�jury that 1nit�at�d i
<br /> �°�"°�'�'�i"�'� DIiE TQ,QR AS A C4NSEQ�ENCE�F: i vns�t ta dea#h
<br /> u�sr d� �
<br /> - i
<br /> i
<br /> 78.i'ART I!.a'�HER SI[�NIFICR�IT�QNDfT1aN5-�ondltions�antr�butin�tv the daath but not result�ng in th�under�ying�aur�girren in PART!. 19.WAS MEENCAL EXAMiNfR
<br /> 8R CC3RDNE�i�dWTACTE�?
<br /> � ❑YE�a �Np
<br /> � �.IF�EiII�ALE: Z1a.MANwER L}F QEATH 21b.IF TRANSPflRTAT�N INJUR Z1c.WA5 AN AUTQPSY PERFDRMED7
<br /> � �Not pr�a+�n�nt wi�hin P�t]►��' �N�Rural �Hvmic(de �DrlverlQp�ra�or
<br /> L#J �pragr�ant at tirrN of dsath ���� ❑ YES � N�
<br /> �y �Acciderrt �Pendiny�M�ation
<br /> ..
<br /> �Not pre�n�nt�but pr�e�n�t wtthi�4x datys a1'c�th �d�r�n �7d WER,E I�UTQPSY FINDINGS AVAiLABL�
<br /> � �e�� �������� T�C�MPLETE CAUSE QF DEATH7
<br /> �Nv�p�n�#.b�rt prepn�t 43 detys ta 1 y+e�ar bs#or�dsa#h �Othar[Sp�cifjr�
<br /> � ❑u��p�w�m�t�e�,�r � �Eg ❑ NE7
<br /> �
<br /> � DAT��F iNJLIRY�Mo.,Qay,Yr.y �.TIAI[E dF iNJURY �c.PLACE C'!F IAlJUFtY-At hvme,farhm,straet,T�ctony,vifics lauilding,con�ruet�on sita,etc.iSpecify]
<br /> �
<br /> � �AIJuRY AT YI�DRK? .DESGR�BE H�111�INJUl�'�CCURREp
<br /> 0
<br /> � ❑vEs ❑No
<br /> ?,�f.LQCATI�N QF iMJ!!RY-STREET 8.Nl]Nl�$ER�APT.N�. GiT�I'ffQWN STATE Z!P GDOE
<br /> 23a.DATE QF E]EATH[Ma.,Day,Yr.) �4a.flATE SfGNEO�Mo.,Day,Yr.) 24h.T�ME DF DEATH
<br /> �� - --------- - _ _- -- - - -- - �,� - � r , PPro�. , ----__----
<br /> � �3b.Qi4T�9��s'�{�iAo.,Day,Yr.j ?.�c.Tl1WE QF�EATH �� ?4C.RR�ND�NCEO[?EAD�Mo.,D�y,Yr. 34d.'i'�ME PRQNUUNGEL3 DEAQ
<br /> �� E3
<br /> ��
<br /> �'� � ��toh�3r 25,��1 Q �2:�5 PM
<br /> .��the beat of my ke�o�vlatly�e,d�alh accun�d�##he t�ris,da�s and plave � Z4�.Qn th��sk af ex�un�nsdon�ndlar i�v�atfon�ir�m�t apin�an deatl�occumed at
<br /> and dus�v thv���y�d.�Sipnaturs�nd 7'�tl� � �u
<br /> � _ � v� tlN#�F d�and pf�vr ae��ue ta tfie cwset��s�Asd.{Sl�r�n�nd T�tFej
<br /> e ~� � S�rah Cars
<br /> � t�nsen,Hail D�pu�County Attvmey
<br /> ��.Dl�T�77 CC�qSE G`[�NTRIB�T'E T�THE D�ATH� ZB�.HA3�RG�IN QR T1S�UE DADHATIC�N B�EN GflNSID�ERE#?? ZBti.V�►AS�t3M$ENT�3RRNTED?
<br /> [�YES []NQ []PR�38A�LY � UNKNQWN ❑1fE� �NQ Not Applir.able tf ZBa ia Nti []YE5 []ND
<br /> • � pa vr n#
<br /> S�rah Carstense�,Hal1 Depu#y Gvunty Attvrney,�3� �. Laca�st,P.�.Box 3�7,Grand Is�and,Nebra�ka,fi8��2
<br /> �a,REGISTRAi�'S SIGNATURF �b,�ATE F1LED BY R��ISTRAR{Mo.,i�y,l�r.i
<br /> �
<br /> QCtObeT 2$,2U'1�
<br /> �
<br />
|