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�tppnr STATE OF NEBRASKA , 1 WHEN THIS !' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 3/21/2017 LINCOLN, NEBRASKA 1 DECEDENTS - NAME (First, Middle, Last, Suffix) Ivelynn Kay Dwinell LL a Q U a 1- 4. CITY ANA STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Olathe, Colorado 7. SOCIAL SECURITY NUMBER 521 -60 -3397 b. FACILITY -NAME moot Institution, give street and number) CHI Health -'St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 6.6303 9a. RESIDENCE -STATE 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 2503 Pioneer Blvd 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Eddie Lee Harwood 13. EVER IN U.S..ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 5. METHOD OF DISPOSITION E Burial •'❑ Donation ❑ Cremation ❑ Entombment 0 Removal ❑ Other (Specify) 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) PART :I. Enter the chaln bf events -- diseases, injuries, or complications -that directly caused the death. DO NOT enterterminal events such as cardiac arrest, •respirato arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Blunt Force Trauma To Chest disease or condition resunmg in. deatht': : Sec(tiontially hst conditions, ti any, tdadmg ro the'cause Intel - on line a. Enter the UNDERLYING. CAUSE (Viseafe of Injury:Met lndlated:::: the events resuhn[g,rn death) .. LAST 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 20. IF FEMALE kf Not pregnard'Whhin past year ❑ Pregnant at time of death ❑ Not pregnant but pregnant within 42 days of death Not pre pregnant days. to 1 year before death ❑ tlnknewn i f pregna within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) February 22, 2017 22d. :INJURY AT !YORK2 ]YES ENO 22f. LOCATION. OF INJURY STREET & NUMBER, APT.NO. Allen Drive, Grand Is and . DA'r: l rF DEATH .(Mo., Day, Yr' 23 DATE S(G D (Mo., Day, Yr.) 3d, To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 201801152 STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH 16a. EMBALMER - SIGNATURE Todd A. Schraq DUE TO, OR AS A CONSEQUENCE OF: b)Car Crash DUE 10, OR AS A CONSEQUENCE OF: 0) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 02:15 PM 23c. TIME OF DEATH 5a. AGE - Last Birthday (Yrs.) CITY/TOWN 69 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient E ER/Outpatient 0 DOA kOb. NAME OF SPOUSE:(FirSt, Roy Dwayne Dwinell 14a. INFORMANT -NAME Roy Dwayne Dwinelt 16d. CEMETERY, CREMATORY OR OTHER LOCATION Pibel Lake Cemetery 21a. MANNER OF DEATH ❑ Natural ❑ Homicide E Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Access Road 22e. DESCRIBE HOW INJURY OCCURRED Decedent's vehicle left a driveway enter roadway in front of oncoming traffic. The point of impact on rlpradpnt's vphirIP wac the rlrivPr's rtnnr 28a. REGISTRAR!. SIGNATURE I C 5b. UNDER 1 YEAR 9c. CITY OR TOWN Grand ',stand 9e. APT. NO. MOS, DAYS dt6 Cori STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 16b, LICENSE NO. 1492 2. SEX Female HOURS CITY/ TOWN Spalding 5c. UNDER 1 DAY STATE Nebraska MINS. 21b. IF TRANSPORTATION INJURY E Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68801 Middle, Last, Suffix) If wife, give maiden name' 2. MOTHER'S -NAME (First, Middle, Maiden Surname) Bonnie Juanita Flemming DATE SIGNED (M _ay, Yr.) March 3, 2017 24E. PRONOUNCED DEAD (Mo., Day, Yr.) February 22, 2017 2 5. DIDTOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ENO ❑ PROBABLY ❑ UNKNOWN E YES NO 127. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sarah Carstensen., Chief Deputy Hall County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 21c. WAS AN AUTOPSY PERFORMED? E YES ❑ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ENO March 14, 2017 3. DATE OF DEATH (Mo., Day, Yr.) February 22, 2017 6. DATE OF BIRTH (Mo., Day, Yr August 24 onset to death: : Immediate ' onset to death 0 Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day Yr.) February 27, 2017 STATE ebraska 17b. Zip Code 68801 APPROXIMATE INTERVAL <. onset to death Immediate 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E YES' ❑ NO ZIP CODE 68803 2 4b. TIME OF D EATH 02:30 PM 24d. TIME PRONOUNCED DEAD 02:30 PM 24e. On the basis of examination and /or investiga ion, In my opinion death occulted at:. the time, date and place and due to the cause(s) stated. (Signature and Title) Sarah Carstensen, Chief Deputy Hall County Attorney 26b. WAS CONSENT GRANTED? Not Applicable if 26a. is NO E YES 28b. DATE FILED BY REGISTRAR ❑ NO o.,Day, Yr.)