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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD=PN-$JL;E, WiTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS !MiCtION,:WHtCff1s-
<br />
<br />:~:~~:U:::'TORY FOR WTAL RECOROS.~~-il~f#f~~-~~,
<br />""'VI"" ..trlrJjN~S'. roSPER- -:
<br />APR 2 7 ZOOS 2 0 0 5115 14 ASSIST~N7:~T,fTEREGiSTRAB-_ , -
<br />LINCOLN, NEBRASKA HEALTH A-ND-ffl.!M~N SEflVICtS'_'"
<br />
<br />STATE ~F~~BRASKA- DEPAR~~~;rF~~f;~Nqtp~N;1~VIC~S :INANCE AND sUP~:~O~5'- 03 8 2 8
<br />
<br />DECEDENT'S.NAME (Flrsl, Middle, Lasl, SUlfi,) 2. SEX 3. DATE OF DEATf2(rO" Day, Yr.)
<br />___Phi_lli.};L__ Male March~, 200~_
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Lasl Birthday 5b. UNDER 1 YEAR 50. UNDER 1 DAY 6. DATE OF SIRTH (Mo., Day, Yr.)
<br />Denver, Ncbr;::lOk;1 Colorado (Yrs.) 46 -~'DAYS HOURS MINS. June 15, 1958
<br />
<br />_.m. -------L_____
<br />7. SOCIAL SECURITY NUMBER ~LACE OF DEATH
<br />5 0 7 - 9 0 - 0 9 0 4 I t!9.S.EIT&: 0 ,~, ,tlenl QIJ:jfB: 0 Nursing Home/LTC 0 Hospice Facllily
<br />
<br />8b2 ;~LIT;:;~ (I~:~:~:n~ ~;v~::~and numb;0_1. U ER/Oulpallenl 2 3 ~ DFe~~StOmkearney Rd.,
<br />~ u l'O\ Xl Olher(SpeCify).p.r.iy..a_te drive ay
<br />-- I Bd COUNTY OF DiATH
<br />Merrick
<br />-----
<br />
<br />
<br />o Nof pregnanl wilhin pasl year
<br />o Pregnanlal fime of deelh
<br />o Nol pregnanl, bul pregnBnl wllhln 42 days of dealh
<br />U Not pregnant, but pregnant 43 days to 1 year before death
<br />i.J Unknown If pragnan.I)Yilhln IhB pa5f yetlr -. - --
<br />22a DATE OF INJURY (Mo, Day, Yr1P-:r'IME OF INJURY
<br />March, 21 2005 ~30 . m 2;33 Ft. Kea~ney Ro_ad- private driveway
<br />22d INJURY ATwo:'1K? 22e~DESCRIBE HOW INJURY OCCURRED
<br />DYES XJ NO Self inflicted gunshot wound
<br />--~'--_._-
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYIfOWN
<br />
<br />.-
<br />
<br />~-
<br />
<br />\'
<br />\,\
<br />"
<br />",-\
<br />
<br />\
<br />
<br />80. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, Nebraska
<br />
<br />9~:~E;C~-;~Ea ..... .... ~TYll
<br />
<br />68801
<br />
<br />9c. CITY OR TOWN
<br />Grand Island
<br />
<br />_m_~ge. APT. ~O 91.~I~C~D~ 1
<br />
<br />1 Db. NAME OF SPOUSE (Firsl, Middle, "est, SUffi') If wife, give maiden nam..
<br />
<br />9d. STREET AND NUMSER
<br />
<br />1404 E.
<br />
<br />8th street
<br />
<br />lOB. MARITAL STATUS ATTIME OF DEATH Xl Married 0 Never Merrled
<br />
<br />U Marriod, bul separaled 0 Widowod U Divorced 0 Unknown
<br />
<br />Tami Voris
<br />
<br />11 FATHER'S-NAME (Firsl,
<br />Raymgnd
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (Firsl,
<br />
<br />Lenora
<br />.--..
<br />
<br />No
<br />15. METHOD OF DISPOSITION
<br />~BuriBI U Donafion
<br />o Cremalion 0 Enlombment
<br />
<br />Tami Proehl
<br />
<br />,~,-". ~~1"c'1}iyo
<br />
<br />16d. CEM TERY, CREMATORY OR 0 E LOCATION CITY /TOWN
<br />
<br />o RemovBI 0 Other (Specify)
<br />
<br />st. Paul
<br />
<br />South Logan Cemetery
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (SlrBBI, Clly orTown, SlalB)
<br />Jacobsen-Greenway Funeral Home 411
<br />
<br />"0" Str st. Paul,
<br />
<br />
<br />
<br />PART l. Enter Ihe r.:h~in of evenls--dlseeses, Injuries, or cornpllcallons--thal directly caused the death, DO NOT enter ~arminal Bvents such as cardiac arrasl,
<br />resplralory Brresl, or venf,icular fibrillallon without showing Ihe etiology. DO NOT ABBREVIATE. Enter only onB caus. on a line. Add Bdditionalllnes II nBce55a'y.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl88ase or condition I'@sultlng
<br />Indeolh)
<br />
<br />(a) Head Trauma
<br />---.".. .
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />Sequonltally11.lcondltlono,II (b) Self Inflicted gunshot._~2_~_
<br />Bny, leading 10 Iho c.u..lI.ted ------ouE-iO,ClR AS A CONSEQUENCE OF:
<br />on line a,
<br />Enterthe UNDERLYING CAUSE
<br />{dls!sss or Injury Ihallnl!IBled (c)
<br />th..venl. ,..ulllng Ind.ath) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />(ef)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condllion. conlribullng 10 Ihe deeth bul nof resulling In Ihe underlyln. ceu,. given in PART I.
<br />
<br />20. IF FEMALE:
<br />
<br />21 B. MANNER OF DEATH
<br />o NBfurBI 0 Homicide
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Driver/Operefor
<br />
<br />o Pessenger
<br />
<br />o Pede.lrlan
<br />
<br />o AccldenfD Pending Investigation
<br />
<br />Il\l Suicide 0 Could nol be delermined
<br />
<br />o Olher (Speclly)
<br />
<br />-"" ,,- .~--
<br />. :.:: i.~-
<br />
<br />~. C INSIDE CITY LIMITS
<br />J/J YES 0 NO
<br />., ."'.
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />Sandqui;;;t____
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c. DATE (Mo., Day, Yr. )
<br />
<br />March?6, 2005
<br />
<br />STATE
<br />
<br />Nebraska
<br />
<br />NE~8c;d~-
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />on'Ollo dealh
<br />
<br />onsel to dealh
<br />
<br />onsello deafh
<br />
<br />onsello doath
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />:!9 YES U NO
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />DYES
<br />
<br />Xl NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />220 PLACE OF INJURY.AI home, farm, .treel, IBclory, office building, construcflon s,le, etc. (Specify)
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />DYES LJ.NQ
<br />
<br />233_F'~' Kear~~x Road
<br />23e. DATE OF DEATH (Mo" Day. Yr.)
<br />H~rch ...21 ,.. 2005
<br />23b. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />Grand Island
<br />
<br />23c. TIME OF DEATH
<br />
<br />z>
<br />~~~
<br />~~~
<br />c..a.. iI( ~
<br />E.eIl t Z
<br />oa:~O
<br />~ "'::>
<br />.D~O
<br />~rr.O
<br />8::;
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />....Mar.h ? q, ? 005-
<br />24c. PRc;.OUNCED DEAD (Mo" Day, Yr.)
<br />March 22, 2005
<br />
<br />m
<br />
<br />23d. To the best of my knowledge, death occurred allhe time, dale and place
<br />and due 10 Ihe cause(s) slaled. (Slgn.lure Bnd Title)"
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TOTHE DEATH?
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />Nebraska
<br />
<br />68801
<br />
<br />24b. TIME OF DEATH
<br />_1:30 p. ._~_
<br />24d. TIME PRONOUNCED DEAD
<br />7:50 a. m
<br />
<br />')
<br />
<br />N~.I ~pilcable II 26B 15 NO U YES _ 1;;1 NO
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />1821 16th Ave Central Cit
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Y,.)
<br />
<br />APR -" 4 2005
<br />
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