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N <br /> ;. <br /> - <br /> ,. <br /> .......::.:. ::.. <br /> �..::�� <br /> C?.': <br /> .: ::,.. ;:.::> <::.:<>: . :: <br /> ;:::.;..:.<:. <br /> ,..... .......:: <br /> :. <br /> :.:.:::: ... : :::..::.:::, <br /> �urial ; ban�atian <br /> ;-.::: <br /> � Traaey Diatz �328 November 21,2012 <br /> ❑Cremation❑�ntnmbment ,��C�METERY,CR�1�lA7�RY OR O�'HEf�LQCA710N C[TY 1 TOWN STAT� <br /> : al::�::; S eci <br /> Q:#��[ri��► :. �he�...P �Yj <br /> .....�. <br /> :,:.'�_:;�a,;::::=,;::::::;: <br /> ., .. <br /> Alda Cemete Alda . �f� ��a <» <br /> ; <br /> �� .: :-.::. <br /> ry <br /> iT..,.... <br /> ::�::'1Ta'::; .L:: E AAi[]MAILING AQaRE55 5tree Ci �r Tnwn ! �4�.Z Co�l�. :::: <br /> :>;: <br /> ,:;:::,.>;:;::: <br /> . <br /> , <br /> ����� ..:...� � ... <br /> ; <br /> ,. , <br /> ::.. .,,:.,,. ,. <br /> ... .,...:, <br /> ;.;. ,,.,., ,;; <,;> <br /> "' Aqfei�'un�r�l H�trie.1123 W.2nd.Grand Isfand.Nebraska ' �8��1 : <br /> CALISE OF DE TH. ee' tru ' n d exam �es .. <br /> :,.:: <br /> :. :.:.;:.. : <br /> ' ;4�8:PM�T'!:�nter�Iia::�h�iti of avl�ti-�li�eases�ir�jurie=�or complitstin+►s�that direcfly r.pu�t�d tfi��cfeatl�:::�1b N0�eiltar ta[�shtalavents weh as card[ac ameat� � <br /> APP Rpi�1M►kTf E1��ERV�Ri. :>::::::; :; <br /> :;:: ;,.. <br /> � � <br /> ;:ie�irat'.'8r. et v� �,ilar Tibrqletion withaat shvwi the etiol .pQ NpT AB�VIAi'�E.�ater or�1;vne C��r�..otf a line.Add add'rtional Ifnes if nace� <br /> ... <br /> ...,.:,...:.::: ;:...::: <br /> ,:....:. 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D E T Oit A A C NSL� LiEMCE OF: se <br /> :`::. :::. ::.:,,._,.:: ,:,:: U �, S � ❑ ; <br /> ,..:.. <br /> ,.. <br /> �. <br /> ,:...: - - <br /> � ::..,- <br /> .:...:.,..:;,. .::.:>: ...:....:� <br /> , <br /> .::: <br /> ;:>.S�<�:' E�sc��h' �r>:h <br /> , <br /> , <br /> ,.... <br /> �, <br /> - <br /> :: ���: . <br /> ,. <br /> ,,;. <br /> ...:,:.. ... .;.:: .-, <br /> , , ;:,. <br /> ::;:. <br /> .,:.,:,. : <br /> any;::[e,adi�:to tE�e_c,�ui�e 33�'` <br /> ..:::.-::. :;.: <br /> ,:..::: <br /> ,.....:. <br /> ...... ..-- , <br /> <_:,_<.: <br /> .. <br /> r►n liiie a::.;.. ..... <br /> ::••: ...: . <br /> DUE Ta�DR AS A C�N5EDl]ENC��F: ; onset to death <br /> Etrisr the tI�tI7ERLYINL3 CAUSE C� i <br /> ,. <br /> (diae8�:�=:injaryfll�t in�+�d <br /> � <br /> •-.::.. <br /> . ,..>.;;: :::.,,..,. <br /> ,.:. <br /> ,,. <br /> ` <br /> ; ; ..: <br /> the�.::.: ,,... �.. <br /> ,.:; <br /> i'►.VR17t8. I :,,..,. ;:::. :.;,;. :•::•.,..,., <br /> <.:.:,.: <br /> ��n��� :::.:�::::: ou�ro v�As A coNs�QUENc�aF: ;:: � o�,set�,�e��, ;� <br /> ,...:. r <br /> ..... _ <br /> u�:r: � <br /> . <br /> ,:::. <.,.<.-::,..: .:,. <br /> ,..:. <br /> , ;,,...:,. :;;:;,;:..:;;, <br /> , d� <br /> : .. ...._ .. :.::.>- <br /> ::: <br /> . <br /> � <br /> ; , ;.: <: <br /> ,.,,., <br /> ..:,; <br /> ,,:,. <br /> .. <br /> :>: <br /> :..:. � :.-::::: <br /> ..:,.::.: , <br /> ,..:., , <br /> 18.PART II.OTHER 51GFlIFICAAIT C[3NaiTIDNS-Condltfans cantributing to ths deafh but nat res�lting in the underlying�ause given in RART I. 19.WAS INEQiCAL EXAMINER <br /> ;Abn�r�nal MRI:Br���,:Pulmanary Hypertension Du�To Illness,S@iZl��@❑l��T�Illf1@S5 ;;�>:_ DR C�RDNER C�NTACTEd? .:. <br /> � ' <br /> YES ":;:: D.. ;>�::>:: ': <br /> ❑ �K.. <br /> ,.. <br /> ,,._.; ,., .. <br /> ,,. ;:.:: ; :..:.: .;.::..:,:: <br /> , „ ...........:..:.: :; ,.;:.::.: <br /> ..,, <br /> F�;:.:. ... .:.;::.:. _ <br /> .:....::...... �;;�<� .:.....: ; <br /> ::. ..... ;:..: <br /> .. <br /> �G;:�. ,..... <br /> ;,....::,... :..,,,;...:,.. <br /> ,,.:>: <br /> 30.#��EM�LEt.`�::� ::. 21a.MANNER OF DEATH .:. 21�i::lF>T�ANSPDRTATIDN lNJUR 21c.WAS AN AUTQPS�.R��F�R�F_4�`:.:� � <br /> .:::.:.;:.::.., <br /> �. ..:..::..,. <br /> - <br /> ....: .:,::.:.;:.: ;:..:.:.,:: ; <br /> :..:.: <br /> t�+�<> Not plti�qna�iE tivithiri pffst year lVatural Fiatnicide E�rF�erlflperamr <br /> � � ❑ � �YE$ ❑Nfl :: <br /> � �Pr�eqnant at time af death �AccideM �Pendin�In�astlqat�on ❑PBf��@� <br /> -• NQ#•pr�4na�t..#ut pr�9Ranf rrithin 42 days of death P4destrfan 21d.WERE AUTOPSY:F!N WNGS AV►Al�.i46L.:. <br /> '�::=:::->;,,>::: : ::: ;:ss.,:;,. Sukida Gouki i�o�t 6e.deiermined'::: ...:..:. <br /> ,.. <br /> �: <br /> ❑ <br /> da s 1 ar brfore dcath `Ot`'S TQ COMPLETE CAf�SE.�SF;Cl�ITkl�;. :- <br /> '1Vot pf#�tiatdr:#tit jtil�a�rt�rK+13 Y ta ye . �er{pecifYy <br /> ::.��:.:.:. ::. <br /> ;:; �. <br /> ::•:. <br /> ' > <br /> ,... ..:: ... <br /> '�'a ';::. : ::::,:.:.:,. ;.::.::: ;::: <br /> ::..:•.: ,::. :.,., <br /> �. •: <br /> ;::,: ;:•: <br /> :>:.:�,y';: YES 3�1�>.:. <br /> .-.: <br /> `�Jn��o�+if. n�ii#apiq�f�;n'thr past y�ar � <br /> ;:.;. <br /> ; <br /> .�� . <br /> �<-: <br /> E. ��a.�ATE QF INJURY Ma.,Da,Yr. 22b.TIM�DF IN,1tJRY 22c.PLACE�F�NJURY-At home,fsrm,street,tacto o#(ice buildi <br /> [ Y � ry, n�,canstructian si�e,etc.RSpeoifY� <br /> v <br /> � <br /> ;:; ; <br /> :,,, <br /> :;: y// {��I t�� <br /> <;�:� d: Jl3 A:r::yy�.' �?:::.:ZZe.DESCRlBE HQW INJIJRY�CGLI � <br /> ' �y.y� ,,::; <br /> . ...... ..�T 5.�� ��.5. .S.'!�/�...... �'..''.''�•' :�..:. .,,.. <br /> ::::v:::: <br /> ;:�::;= > <br /> ;,;;., <br /> ,:.. , ; ; <br /> ;. <br /> ;:;; ::: < <br /> ,.:,. ;;:;::.::;<:;: :::i::: ;:: <br /> ;:..:::..::.... :.::. <br /> Y�� N�= <br /> ,:, � ..<.:.,: <br /> :.:. <br /> . <br /> :: : <br /> .. 22I.LD�ATl4N�F IM.11]F�Y-5TREE7�NUMB�R.APT.NQ. GITYlTOWN STATE ,,.:�IP G�O� <br /> ,.. <br /> ,;;�3a.Di4'#'E f�l�A7H Mo.0 Yr. Z4a.[?AT�51GNE0 Ma.,aa,Yr. 24b.TIME D��EAT#�1 ;::` ; <br /> <:;.: <br /> ;;:. <br /> ;:.::. :.::: ,.;,...,.. <br /> [ , �]►� ::.:>:;. :.:..:.... <br /> � Y :: ;.:::: <br /> :..:. ::::: <::;;:: ,,..z ;:�;::::::. <br /> .:::.:: .:..::::.:.: .:.:. .::.::, <br /> ; ::.:: ::.: <br /> a:::::. g. '.:::. <br /> ;::.:... <br /> >:::.�' ;;. �;,1:- ,;�' � <br /> ,=<;Na�sr� e S 2�12 <br /> . <br /> U <br /> .;.:..:.;,.. ,: <br /> .... �;:.:::: .::. <br /> :.:::":.:.: � ;.:.. :..•..... .,.,..-:. .:,...;.,..:. ;..:. _.,:... ... <br /> ':.` ::;::. <br /> ,:.::<. :.: <br /> '::: :"::.= <br /> ; <br /> :.::.: � >:..;.. . ,-..:; ; = A Mo. a Yr. 24d.'f'IM�PRON � <br /> :..��.A�l�l���+1�7{Mo.�Qay�Yr.� 23c.'FIME OF DEATH �Ic.PRt�NaDUNC�D I]� a� �D Y, 01�N��D�AQ..:;:�;;` �::° <br /> ;::.. ::.: <br /> .;::: : <br /> ..,.>.: <br /> _ ;:..:.:.:.:.:.:: <br /> ;:.:::..: <br /> :::�x">�"::�; ..::::.; ,:,:.; '�::..: �.:::::,..: ..::.... :::.::.:::. <br /> . <br /> . �v i December 3 ��12 44:55 AM a a� <br /> �a � 3d.Tq thv�vst pi my kr�orvledge,death vecurred at the tane,data and place �W�� �,p���gis af axaminatlnn andlor inveslipation,kn my opinion death ocr.urned at <br /> oa xnd due ia the cauae�s�gtaisd.{8ipnature and Title) o p p tha time,date and p4ace and dua to the eauae(s�ptated.{Sipnsture rnd Title] <br /> �..ue ,;:.:. . :.:_ ;:, �::�:v <br /> ;>;-aE:::<;.:>; . 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