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<br />STATE OF NEBRASKA
<br />4,k1t~}4111/ 7 t o4t, 54'. . . ' }•
<br />WHEN THIS ';i 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 OF ISSUANCE
<br />7/16/2019
<br />LINCOLN, NEBRASKA
<br />01905713
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Pursuant to sec tion 30-2413, demands for notice which may affect the estate of the decea: ed are filed with the county court in the county where the decedent resided at ti e time of death. 1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jerod Dean Tiff
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 25, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />35
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 2, 1983
<br />7. SOCIAL SECURITY NUMBER
<br />507-11-7219
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8bFACILITY-NAME (If not Institution, give street and number)
<br />North Road And 13th St.
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA `9 Other; 5pec!f111••terscCtior,
<br />Sc. CITY OR TJWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a.`RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />222 E. 11th Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY UMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married E Never Married
<br />❑`Married, but separated ' ❑ Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Jackie Dean Tiff
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Janet Marie Rose
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk,) No
<br />14a. INFORMANT -NAME
<br />Jennifer Tiff
<br />14b. RELATIONSHIP TO DECEDENT
<br />Sister
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />May 26, 2019
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PARI I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Blunt Force Trauma To The Head And Neck After Motorcycle Accident
<br />disease or condition resulting
<br />onset to death
<br />Immediate
<br />in death) -•�-
<br />:'. DIJE TO, OR AS A CONSE0t!F■?'
<br />Sequemialiy list condn ons, if b)
<br />any, leading to the cause listed
<br />line
<br />onset to death r-
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE: -
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />® Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />E Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown 1f pregnant withdt the past year
<br />❑ Suicide 0 Could not be determined
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />May 25, 2019
<br />22b. TIME OF INJURY
<br />07:12 PM
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />Intersection
<br />22d. INJURY AT WORK?
<br />❑ vEs , NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Decedent was intoxicated and entered roundabout at North Road and 13th St. at a high rate of speed, leaving driving
<br />lana and striking the mprtian fiprPripnt and mntnrcycIP clivi and struck a rurh head -first, coming to rest nn thin mpnian
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />North Road And 13th Street, Grand Island Nebraska 68803
<br />To be completer by
<br />MEDICAL CERTIF'ER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />To be complete.! by
<br />CORONER'S PUY: ICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />July 1, 2019
<br />24b. TIME OF DEATH
<br />Approx. 07:12 PM -
<br />23b. DATE S(GNFD (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. i' ONOUYt:ci. ur:.:WJ/Mo., Lay, 't..,
<br />May 25, 2019
<br />2•i,.. Tia_ 773,.0.....::0 __=.�
<br />07:15 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Sarah Hinrichs, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY E UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sarah Hinrichs, Hall Deputy County Attorney, 231
<br />S. Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />.„00,..,::-z..---,4,,e------
<br />28b. DATE FILED BY REGISTRAR (Mo., Ray, Yr.)
<br />July 10, 2019
<br />
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