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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Kristine Jean Olson 2. SEX Female $. DATE OF DEATH (Mo., Day, Yr.) May 31, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Columbus, Nebraska 5a. AGE - Last Birthday (Yrs.) 50 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) March 1, 1965 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -98 -0413 8b. FACILITY -NAME (If not Institution, give street and number) MM 419 Interstate 80 Ba. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ® Other (SpecifyinterState 8c. CITY OR TOWN OF DEATH (Include Zip Code) Greenwood 68366 8d. COUNTY OF DEATH Cass 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1711 N. Broadwell Ave. 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS O YES ❑ NQ 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Timothy Ernest Olson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Darrel Frank Barrett 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Jeanette Phyllis Hamann 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Timothy Ernest Olson 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) June 3, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER r 18. PART I. Enter the chain of events - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Blunt Force Trauma To The Chest, Abdomen, And Extremities disease or condition resulting onset to death Seconds in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b)Automobile Collision Seconds any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? r ® YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year Pregnant at time of death ❑ ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ® Unknown if pregnant within the past year 21a. MANNER OF DEATH ❑ Natural ❑ Homicide ® Accident ❑ Pend Investigation ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ) Driver /Operator Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ® YES ❑ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ® YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) May 31, 2015 22b. TIME OF INJURY Unknown 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Interstate 80 22d. INJURY AT WORK? ❑ YES ® NO 22e. DESCRIBE HOW INJURY OCCURRED Vehicle driven by decedant was struck by another vehicle while traveling down 1 -80 causing decedent's vehicle to spin out of control, roll, and eject the decedent from the vehicle. 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE MM 419 Interstate 80, Greenwood Nebraska 68366 W m F z 1 -"J ) 23a. DATE OF DEATH (Mo., Day, Yr.) z e LS g i i k s t o. • z N o b u w z o p ~ '2 6 24a. DATE SIGNED (Mo., Day, Yr.) June 30, 2015 24b. TIME OF DEATH Unknown 23b. DATE SIGNED (Mo., Day, Yr.) 123c. ( TIME OF DEATH 1 24c. PRONOUNCED DEAD (Mo., Day, Yr.) May 31, 2015 24d. TIME PRONOUNCED DEAD 06:37 PM u O 23d. To the best of my knowledge, death occurred et the time, date and place ■ o 9 and due to the cause(s) stated. (Signature and Title) l 24e. On amitndlor investigation, in my opin dere at the the time date sis o! and exa place na and ion a due to the cause(s) stated. (Signation ure and ath occur Title) Nathan Cox, Cass County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a, HAS ORGAN OR TISSUE r • ATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 0 NO 26b. WAS CONSENT GRANTED? Not Applicable 1f 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Nathan Cox, Cass County Attorney, 346 Main St, Plattsmouth, N braska, :8048 1 28a. REGISTRAR'S SIGNATURE ,j- 280. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 1, 2015 DATE OF ISSUANCE S" AfVLEY S £GAPER, • ASSISTeNT ST TE,,REGIST84 D'EPARTIVT CHfALTH AND^ LINCOLN, NEBRASKA HUMAN SERVICES 07/06/2015 STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI4E ,_. CERTIFICATE OF DEATH 101,602960 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND ,HUMAN SERVICS, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA bEPARrIWINT OF HEAl ANDS HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAiL'R l r 15 03794