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<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 OFISSUANCE
<br />6/9/2020
<br />LINCOLN, NEBRASKA
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<br />20210229,
<br />44,4.41.44 4 .,4.41.441 rat_
<br />SARAH BOHNENKAMP
<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 />1. DECEDENT'S -NAME (first, Middle, Last, Suffix)
<br />Tabitha Ann Van Pelt
<br />4. CITY AND STATE OR.TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Fayetteville, North Carolina
<br />7. SOCIAL SECURITY NUMBER
<br />508.84-2706
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />1-80 mile marker 356
<br />80. CITY OR TOWN OF DEATH (Include Zip Code)
<br />York 68467
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET ANO NUMBER
<br />2850 Washington St
<br />9b. COUNTY
<br />Lancaster
<br />10a, MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />0 Married, but separated 0 Widowed E Divorced 0 Unknown
<br />37
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Lincoln
<br />HOURS
<br />MINS.
<br />10 01095
<br />3. DATE OF DEATH (Mo., day,
<br />April 18, 2010.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 2, 1973
<br />OTHER ❑ Nursing Home/LTC
<br />0 Decedent's Home
<br />E Other (Specify)Highway
<br />I8d. COUNTY OF DEATH
<br />York
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68502
<br />Hospice Facility
<br />9g. INSIDE CITY kiM179
<br />[ YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11, FATHER'S.NAMe (First, Middle, Last, Suffix) 112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Allen Gewecke
<br />j M Paulette Furmape
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />®'Burial Donation
<br />0 Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Allen Gewecke
<br />16a. EMBALMER -SIGNATURE
<br />Jon Brouillette
<br />16b. LICENSE NO.
<br />1061
<br />14b. RELATIC
<br />Father
<br />pHIP TO DECEDENT
<br />16c. DATE (Mo., Day, Yr.)
<br />April 23,2010
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Lincoln Memorial Park Lincoln
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Lincoln Memorial Funeral Home, 6800 S. 14th Street, Lincoln, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- diseases, injuries, or complicationsdhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />IM
<br />disease or Condition resulting:
<br />Indeath) _ ....
<br />respiratory arrest, or vemricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />MEDIATE CAUSE (final a) Blunt Force Trauma
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />online a.
<br />Enter the UNDERt:YINt3 CAUSE
<br />(d)se9§§ or injury3hatlnitlated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />8.<PARTI1. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />17b. Zip Code„
<br />68512
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Immediate
<br />onset to death
<br />onset fo death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />EYES ❑ NO
<br />20. IF FEMALE:
<br />❑ Not pregnant width\ past year
<br />Pregnent at time Of death
<br />❑: Nat pregaant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />E Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />E Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />RIDriver/Operator
<br />0 Passenger
<br />❑Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ENO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO..
<br />2241 DATE OF INJURY (Mo., Day, Yr.)
<br />•April 18, 2010
<br />22b. TIME OF INJURY
<br />04:32 PM
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,. etc (Specify)
<br />6 Miles East Of MM356, Interstate 80, York County, Nebraska
<br />22d. INJURY AT WORK?
<br />❑ YES. ® NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Decedent was the driver of a motor vehicle that was involved in a rollover accident.
<br />22I, LOCATION OF INJURY STREET 8 NUMBER, APT.NO.
<br />MM356 Interstate 80, York
<br />CITY/TOWN
<br />STATE
<br />Nebraska
<br />ZIP -CODE
<br />68467
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<br />gO 36,TO the best Moly knowledge, death occurred at the time, date and place
<br />and duet* the cause(s) stated. (signature and Title)
<br />a
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />,❑ YES :E NO :0 PROBABLY ❑ UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />April 21, 2010
<br />24b. TIME OF DEATH
<br />Approx. 04:32 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />April 18, 2010
<br />24d. TIME PRONOUNCED DEAD
<br />05:10 PM
<br />24e. On the basis of examination and/or Investigation, in my opinion dIrrithddCurord et
<br />the time, date and place and due to the cau e(s) stated. (Signature end Title)
<br />Tim Sieh, York County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES
<br />NO it
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Tim Sieh,` York County Attorney, 510 Lincoln Ave, York, Nebraska, 68467
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 22, 2010
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