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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC9- SECTION, .WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE -' JUN 2 7 2005 ASSI 1:7 S]A�y7` i1TEfi$ €14AR LINCOLN, NEBRASKA HEA AND HL" pvlGE$ 20050758 - _ -- STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANUSUPPORT O 06976 CERTIFICATE OF DEATH 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEA;H (Mo,, Day, Yr.) Gregory Phillip Reinke MALE June-" 2005 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a, AGE -Last Birthday 5b. UNDER t YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) MOs. DAYS HOURS MINS. Beatrice, Nebraska 44 June 29, 1960 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH -... 508 -88 -1645 _ HOSPITAL, ❑ Inpatient 4INE ❑Nursing Home/LTC Hospice Facility 8b. FACILITY -NAME (If not institution, give street and number) ❑ ER /Outpatient G9 Decedent's Home 3617 Curran Ave., #15 ❑ D34 ❑ Other(Soecifvt Be. CITY OR TOWN OF DEATH (Include Zip Code) ed. COUNTY OF DEATH W Grand Island, Nebraska �T Hall _... 9a. RESIDENCE -STATE 9b. COUNTY 9c. CITY OR TOWN Nebraska Hall Grand Island _..._ _ 9d. STREETANO NUMBER ?!.,ART. NO 91, ZIP CODE gg. INSIDE CITY LIMITS Married U Never Married tob. NAME OF SPOUSE First Mid 3617 Curran Ave. 15 68$03 � Es ❑ No Y..._.. 10a. MARITAI, STATUS AT TIME OF DEATH ❑ ( die, Last, Suffix) If wife, give maiden name. V C& Married, but separated ❑ Widowed ❑ Divorced U Unknown Tammy ( NMI) Rimel 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lyle (NMI) Reinke Connie (NMI) Lee 13. EVER IN U.S. ARMED FORCES? Give dates of service If yes. 14a. INFORMANT•NAME 14b, RELATIONSHIP TO DECEDENT (Yes, no, orunk.) NO Tammy Reinke Wife 15, METHOD OF DISPOSITION 16e. EMBALMER•SI ATUR 15b. LICE 16c. DATE (Mo., Day, Yr. ) K Burial El Donation / �l.P June 10, 2005 ❑ Cremation U Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE E3 Removal U other (specify) Grand Island City Cemetery, Grand Island, Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stela) 17b. Zip Cade Kleine Funeral Home, 3213 W North Front St., Grand Island, NE 68803 18. PART I. Enter the Chain of events -- diseases, injuries, or complications.-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular Ilbrlllation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Imes If necessary. IMMEDIATE CAUSE.: IMMEDIATE CAUSE (Final (a) Asphyxia disease or condition mulling DUE TO, OR AS A CONSEQUENCE OF, In death) Sequentially list conditions, If Self-inflicted nflicte d h a n g i n n leading cause DUE TO, OR AS CONSEQUENCE OF: on fine a, ny Enterthe UNDERLYING CAUSE 23c. TIME OF DEATH. �a (disease or Injury that Initiated (c) the events resulting In death) LAST DUE T0, OR AS A CONSEQUENCE OF' APPROXIMATE INTERVAL I I onset to death limmediate I onset to death I immediate 1 onset tc death I I I onsettodeath I 18. PART 11. OTHER SIGNIFICANT CONOITtONS•Conditlons contributing to the death but not resulting in the underlying cause given in PART I, 3617 Curran Avenue #15 19. WAS MEDICAL EXAMINER 23a. DATE OF DEATH (Mo., Day, Yr.) z z OR CORONER CONTACTED? ny 23b.DATE51GNEb(Mo.,Day,Yr.) 23c. TIME OF DEATH. �a X] YES U NO 20. IF FEMALE: 21a. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? U Not pregnant within past year ❑ Natural 0 Homicide ❑ Driver /Operator at the time, date and place $ w r] O C1 Pregnant at time of death ❑Accident❑ Pending investigation ❑Passenger yy�-� ❑ YES TJ NO U Not pregnant, but pregnant within 42 days of death Suicide ❑Could not be determined C1 Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO ❑ Not pregnant, but pregnant 43 days to t year before death 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ Other (Specify) COMPLETE CAUSE OF DEATH? ❑ Unknown It pregnant within the past year .., ❑ YES [A NO 22a. PATE OF INJURY (Mo., Day, Yr) 22b. TIk1E OF INJURY 22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 06/06/2005 10:00 a m home - 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED -- U YES (5NO Decedent hung himself by the neck with a rope. 22f. LOCATION OF INJURY • STREET R NUMBER, APT, N0, CITY/TOWN 3617 Curran Avenue #15 Grand Island 23a. DATE OF DEATH (Mo., Day, Yr.) z z ny 23b.DATE51GNEb(Mo.,Day,Yr.) 23c. TIME OF DEATH. �a xr J Eaz M Ew¢i 0 on o 9 23d.To the best of my knowledge, death occurred at the time, date and place $ w r] O FQ and due to the cause(s) stated. (Signature and Title) V '70 O W0 O U o 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DON) STATE ZIPCODE NE 68803 24a. DATE SIGNED (Mo., Day, Yr.) 24b, TIME OF DEATH 6- Ik G�- 10 : QO a m 24c. PRONOUNCED DEAD (Mo., Day, Yr,) 24d, TIME PRONOUNCED DEAD 06/07/2005 22 :30 pm 24e. On the basis of examination and /or investigation, in my opinion death occurred at k the limg4ate and plUeAnd due to the cause(s) stated. (Signature and Title ) T 26b. WAS CONSENT GRANTED? ❑ YES IS NO ❑ PROBABLY ❑ UNKNOWN U YES_ X) NO V Not Applicable If 26e Is NO ❑YES Ld Id0 27. NAM E, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) JACK Zitterkopf, Deputy Hall County Attorney, P.O. Box 367, Grand Island, NE 68802 28s. REGISTRAR'S SIGNATURE ` 1/1 1 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)