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� ,itigeas,k STATE OF NEBRASKA g 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 3/5/2018 LINCOLN, NEBRASKA 201802179 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Dustin Jo Shaw 4, CITY: AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 508 -25 -3749 _ 8b. FACILITY -NAME (If netInstitution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 7687 N 130th Road Oa. MARITAL STATUS AT TIME OF DEATH ❑ Married ® Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Russell Deon Shaw 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) Yes Dates Unknown 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, If ;- b) any leading to the cause listed on Tine a DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) tdisease or injury that Mitiatetd the events resulting In death) DUE TO OR AS A CONSEQUENCE OF: LAST d) 20.1PFEMALE: ❑ Not pregnant` Within past year ❑ Pregnant at time of death ❑ Not pregnanL@but pregnant within 42 days of death ❑ N ot pragnanL but pregnant 43 days to 1 year before death 0. Unknown if pregnant within the past year 5a. AGE - Last Birthday (Yrs.) 28 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Laurie D. Sheffield CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH ❑ Natural ❑ Homicide ® Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5b. UNDER 1 YEAR M OS. DAYS 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES El NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Gail VerMaas, Hall Deputy County Attorney, 231 S Locust, Grand Island, Nebraska, 68801 28a. . REGISTRAIES SIGNATURE /lam / 45- CA _ 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) January 10, 2018 6. DATE OF BIRTH (Mrs; Day, TO November 15, 1989 8a, PLACE OF DEATH HOSPITAL ❑ Inpatient Y,] ER/Outpatient ❑ DOA OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Cairo 9e. APT. NO. 9f. ZIP CODE 68824 lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 12. MOTHER'S -NAME (First, Middle, Maiden Surname) ` Shelly Ann Gregg 14a. INFORMANT -NAME Russell Deon Shaw 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Crematory CITY / TOWN Grand Island STATE Nebraska 8. PART I. Enter the -chain of events diseases, injuries, or complications -that directly caused the death. DO NOT enter ternunal events such as cardiac arrest, respiretery 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 The Head And Neck disease or condition resulting 16b. LICENSE NO. 1397 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. 21h. IF TRANSPORTATION INJURY RI Driver /Operator ❑ Passenger Pedestrian ❑ Other (Specify) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? El YES 0 N January 17, 2018 9g. INSIDE CITY LIMITS ❑ YES ® NO 14b. RELATIONSHIP TO DECEDENT Father 16c. DATE (Mo., Day, Yr.) January 23, 2018 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death 10 Minutes onset to death onset -to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED'? ® YES. Q NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE +CAUSE OF - DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Intersection 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY January 10,:2018. 04:55 PM 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED OYES J NO The deceased ran a stop sign while eastbound on One R Rd. and was struck by northbound pickup. Deceased was trappPri and had to ha P xtriratPd from vphir1P 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE 90th And One R Road, Cairo Nebraska 23a. DATE OF DEATH (Mo., Day, Yr.) 2 4a. DATE SIGNED (Mo., Day, Yr.) A ul i' January 16, 2018 24c. PRONOUNCED DEAD (Mo., Day, Yr. � T t ii U Z January 10, 2018 O 3d . To the best of my knowledge, death occurred at the time, date and place S w i 24e. On the basis of examination and /or investigation, in my opinion death occurred at 8 c and due to the cause(s) stated. (Signature and Title) g z the time, date and place and due to the cause(s) stated. (Signature and Title) 12 W - Gail VerMaas, Hall Deputy County Attorney ZIP CODE 68824 24b. TIME OF DEATH 05:44 PM 24d. TIME PRONOUNCED DEAD 05:44 PM 26b. WAS CONSENT GRANTED'? Not Applicable if 26a is NO ® YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)