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<br />- z*LEONNM AA, o kestarareb! .5,),L)05
<br />• -WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE •A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />• DATE OP ISSUANCE
<br />06/20/2016
<br />LINCOLN, NEBRASKA
<br />Ui
<br />z
<br />1. O4AM mr M$ d1, Lat5t,
<br />JOON LEIte Giver
<br />A. CITY AND a CATE OR TERRITORY, OR FOREIGN COUNTRY OF 31RTN
<br />Keame, Nebraska
<br />1. sacust,smsore RU
<br />506-68-0213
<br />FAcsu FY 4t Qt hriatitatIon, woo sod 14ml:40
<br />Columbus Community Hospital
<br />ss any co lovas tEATH (brolucto Zp Code)
<br />Coiurrtbi..is BI:t602
<br />AL RESIDENCE'S
<br />NettraSka
<br />01t STREET AND NOMSER
<br />122 , -
<br />37
<br />104 MAR - r TH
<br />ITAL S AT tmE OF DEA MADM A 0 Novor AttorimA Ibt NAME 01;
<br />u. MAW toot SAE watt tw o roaldott name.
<br />0 44U Tv 0 ',FA r2 c tle*no-cen cydney Heorcx
<br />11 FaITHER SNAME (Prot LMIL L.,et MAIO 12 M0INER *NAME tratt, EitO MA5 SNTTIATVE)
<br />ettton. Oliver Srmtn
<br />14b RELATIONSHIP TO OEEDANT
<br />Spouse
<br />i9 °Al . t (91 „Day, Y..p
<br />jFeb 9 , 2016
<br />03 t3. EVER IN U A ARMED FORCES 7 ON* tistos at stuNtoe If Too I 14a. INFOEtMANILNAIRE
<br />(Tot, N, A Unb. Ho
<br />Is, memo Or TASPOSMON
<br />0 655,5 005555.
<br />rijort55.5555 0E555,5555.5t
<br />• ••Ottotoutot DutooDANITI
<br />STATE OF NEBRA
<br />201604364
<br />V-A - DEPARTMENT OF HEALTH AND HOMAN SERVICES
<br />ERTIFI ANSEPL
<br />DOLTATY
<br />Cydney Oliver
<br />Ert
<br />5,1111:!.?:A.55CIT
<br />1E4. COLLVallY. CREMATORY OR OTHER LocAttpo
<br />Cent, at Nebraska CrernatIon Services
<br />E. EA AGE-Lost flitthtial .5b. UNDER 1
<br />ITML)
<br />63
<br />113, PLACE 01 EARTH
<br />141.13 Mptillotst 0,1",tt.gf,L0 Nuroingi4ontoiLTC 0 Hos*. ForMily
<br />0 ER/Outbotiom 0 Doom:ATM* Hums
<br />0 DOA 0 OtbottSpoolty)
<br />Ed. COUNTY OF DEATIt
<br />1 Platte
<br />uo. CITY OR TOWN
<br />Platte ColumbuS
<br />150. APT. NO [9 TIP CODE
<br />65601
<br />Tab LICENSE NO.
<br />_ ,
<br />?
<br />CiTYTTOPITT
<br />SIDODT:
<br />.qt,..„ tame AND MAILING ADDRESS tARrst, Ody M Town,EITAA33
<br />Home. 1123 W. 2nd. Grand Island. Nebraska
<br />:••
<br />CAUSE OF DEATH (Soeinstruetions and ex
<br />Y
<br />oLoorea, Liadez,lr 41 dm*. ILO W( skutilmoonfiaa . •
<br />IAy `...4`lit4g`tor fiLILLsti. w&g:tt shiL.ALI Eta 00 D !fin AfsiggE Emor sob orto oitoo 55 5555, AOti 544515550 M 55.5.55551T
<br />PAMEDTATE CAUSE:
<br />IMMEDVITECA• :USE
<br />GrOil0Oicktoso40 tOOltierto
<br />INEAM11)!:.::
<br />•
<br />• , I vi Y•6
<br />DUE TO, OR AS A CONSEQUENCE OF: ••••!!!tpg
<br />At
<br />t' to5 t Alt • it•
<br />DUE TO, OR M CONSEQUENCE OF:
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />16 20780
<br />3. DATE OF DEATH (Mo.,Dity,TT,I
<br />ebruarys.2O18
<br />S. DATE OF RECTA IMA, Day, Yr.)
<br />onset to doeth
<br />STATE
<br />Nebraska
<br />68$01
<br />„—
<br />APPROXIMATE INTERVAL
<br />onset to ASSES
<br />• A! L „`S!
<br />olitat t,i7■ ilsokttt
<br />.1.4.14
<br />onset to dot),
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<br />goy, laustbrtu to tha 50555 IMOLI
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<br />V.4
<br />EUNW tAb UNt)LALYIND CAUSE e)
<br />tbisitotto injury/051 Intatad
<br />events tiatekAltr tu DUE TO, OR AS A C
<br />LAST
<br />.fittETARE3, OTTER SiGN IFiCANT C ROSTIONE , Co tiAss Su.SS1ibUU*5 to 4 SOMA but S5SttRO esARISSARa
<br />•
<br />24. IFFELIALE:
<br />10!!.t.t:00.0.0ikoit.:othi. pus year
<br />nest 51515w 0/ 55551
<br />nflociirivaiiia, but procount atalaatAt *Iva ot, death
<br />°Not prourtant. but pregnant 43 Sops to 1 year before dotth
<br />OtIolutown
<br />it reEmit Litbln the past you
<br />•
<br />2,35. DATE OF MJURY (104., Day, '0.1 ! 325 yt
<br />FIJI/RI
<br />524 Kit:RV AT WORM, 22*. ORME 4QV1 ItC)UftY OCCURALD
<br />Oyes pi N.
<br />215. MANNER OF DEATH 1 IF THAHSPOR1;174; t Ptoner
<br />0 U Asuu Could ROTEL t,eitiord PAisdoku Mutat OWN% C:"Ivtil°i'erat"
<br />Ct dOissr
<br />0,..,,'"'"ur*, 0 WoPteRto
<br />0 nisei ISpot Ey)
<br />sr. Loommk:oF DEZURT . Men' a NUMSER, APT. NO, enateroiast :..•••
<br />23a. DATE OF DEATH ;MR. 3E1, vs )•
<br />. .
<br />22s. PLACE OF INJURY At:OM igML 4 fi.l51orl..“ bukt 0-mults gibs OttL (Stme4) •
<br />20a ttfikV AAR'S 8 OP
<br />ton In PA
<br />T P. TO. WAS S EXAMINER
<br />ON CORONER 004/ken:DA
<br />cj YES NO
<br />L 21o. WAS AN AUTOoST PERFORMED"
<br />YES Pi NO
<br />214. WERE AUTOPSY MANGE 4v,s.a.,itst,e
<br />to cotneLeTsCAtlee OP DEA ENT
<br />0 yea 0510 •
<br />STATE 215 CODE
<br />555. TIME OP DEATH
<br />Va. DATE. EtOT.4. Wu., toy. FE)
<br />t - 1 7 5, PRONOUNCED DEAD It**. Day, Yr.)
<br />55! • .
<br />OEAE :. •
<br />SEt
<br />254. TIME PRONOUNCED DEAD
<br />• • - Mt DATE MONAD (APL, Day, Yr ) ' 255, TIME OF DEATH
<br />• .M0143iF ' 6 .t.-■ v f e ' 0 4i ; r M
<br />1 eay. ro. Um boat of my topitZs4ge, dooth 04430114 at the Nom, dottEATIC) Moo. `
<br />• 4E4 dusts the bauxOto) stated Ittignoturo area TWO
<br />,v e 1 4 _,
<br />ei
<br />i
<br />14 DO 'FOREDO° USE DONTRIEUTE TO THE DEATH? ss 'I 5 ''!'' OR: DOMItON SEAN CONSIDERED/ 5b WAS CONES/IT GRANTED/
<br />OYES 0 NO 151 PROZADLY 0 L1N115OWN yes D Pie 1 Tjgt APES 515 IL , it) 1;3 YES NO
<br />ET NANte, TITLE AND ADDRESS OP CERIV■ik ;Typal se Yriral , • a 40 i 1 ; he t 4 ( id Cis 4 ypt 1 11.: LI t.LtL 4? af 1 (4 . f La 4. 4 1‘:00 ' ' 4 Shial Cat,taihy„ 41 eI
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<br />1Tuut pot. 554 Moos 554 two to the touts(s) MENU, (SIETIONITLL7WTIPAI•.::
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