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<br />STATE OF NEBRASKA
<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 C.OPY OF THE ORIGIN. ..:.4.L ..,~.. ~.... ..'............'_..... ..!l.,.M'-......O.... ..... ON..." '. Fl4.E, ~.. ITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI~"",(jN, Jll{HICH IS
<br />THE LEGAL DEPOSITORY FOR VI!AL RECORDS. . .... .. ..... ....I:..:-.::-.......'''-.~.~.--:c+:~.:.:~-'. .....;...'. C~(),r1f.'. _~~ .
<br />
<br />DATE OF ISSUANCE . ."_ __, . '~,"'.c_ ....
<br />SEP 1 8 2006' /: ~./",~ ' TANi.~jS. COOPER
<br />; . A,,/STA,tVT StATE -REGISTRAR
<br />LINCOLN, NEBRASKA 20 0 6 0 90 23 HEIi)iTH AND'HUM~N5ERVIt?ES
<br />
<br />___ STATE_OF NEBRASKA - DEPA~G~~~I~~~~;~N~ ~U~~~~~~~CES FINANdEAND SUPPORb6.....2_9. 9 8 5
<br />
<br />1.DECEDENT'S.NAME (Flrsl, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day. Yr.)
<br />___..]<;velY!l ___Garrett Female ~ugust 16. 200?__._
<br />
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE-Lasl Birlhday 5b. UNDER 1 YEAR
<br />
<br />(Yrs.) 85 MOS. DAYS
<br />
<br />5c. UNDE,R 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />Pearl City. Illinois
<br />
<br />July 28. 1921
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />327-18-6408
<br />
<br />8a. PLACE OF DEATH
<br />~:
<br />
<br />o Inpalienl
<br />
<br />QIJ:IEB: 0 Nursing Home/LTC 0 Hospice Facilily
<br />
<br />FAr.: II.!TY-NAMF _JIf ",rl.l?t in~'flltJlJ(}n, give strp..fl ,,8.nd number)
<br />
<br />U ER/Oulpalienl
<br />
<br />iN Oocedent'. Ham.
<br />
<br />Home:
<br />
<br />~--
<br />
<br />423 N. Sherman
<br />
<br />u lX)\ 0 Olher (Specily)__..
<br />
<br />~N~~O{~EATH -- '.---
<br />- I~c CITYO~~::~d Island ---
<br />.._~ - =rge A~tz~~~~~_.: ~;~~~:CITY~IM~:S
<br />
<br />lOb. NAME OF SPOUSE (FlrSI, Middle, Lasl, Sulllx) If wif., give maiden nam..
<br />
<br />\
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />ga. RESID;:~S;A~~S ka ~ I~b ~~U~~l
<br />
<br />9d. STREET AND NUMBER
<br />423 N. Sherman
<br />
<br />lOa. MARITAL STATUS AT TIME OF D"ATH 0 Married 0 Never Married
<br />
<br />o Married, but separaled lXWldowed 0 Divorced 0 Unknown
<br />
<br />11. FATHER'S.NAME (First,
<br />
<br />Middle,
<br />
<br />L.'I,
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Gast
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Son
<br />
<br />16c. DATE (Mo" Dey, Yr. )
<br />August 22. 2006
<br />
<br />STATE
<br />
<br />Missouri
<br />
<br />PAi-1I I. En'., Ihel1haio.llL...~"dl.."M, inlij'lell, or oompllcaffo~'.".llIal alr~c"y cau.ed Ihe deiiii;. bo NOT enier t.rminelevent. .ueh as cardlec .rre".
<br />respiratory an'l~$t, or ventricular Ilbt'lllfl.tion wit~OUI stloW,ing the el,lO,logy. DO NOT AaBRJii:\tlATE,'Emaf onJy..o.ow.cause on a line. Add addilioniillines if nec:eaaary.
<br />
<br />IMMEDIATE CAUSE.
<br />
<br />onset 10 dealh
<br />
<br />IMMEDIA T" CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />
<br />(a) cardiac arrest-heart attack
<br />
<br />immediate
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onSet 10 death
<br />
<br />S'quenlially list condlllons, II (b) ~e r ten s io n
<br />anY,le.dlnglolhocau.elistod -'DUE TO, OR AS A CONSEQUENC~'
<br />on linea.
<br />Enler 1110 UNDERLYING CAUSE
<br />(dl..... or injury th.llnillalod (c)
<br />the events resulting in death)
<br />I.A';T
<br />
<br />I
<br />I
<br />._~(2ars
<br />I on.ello de'lh
<br />I
<br />I
<br />
<br />~--
<br />
<br />
<br />DUI: TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 der:lth
<br />
<br />(d)
<br />
<br />18. PARr II. OTH"R SIGNIFICANT CONDITIONS.Condlllons conlribullng to Ihe dealh bUI nol resulling in Il1e underlying cau.e given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />:Ii YES 1!I""No
<br />
<br />20. IF FEMALE:
<br />~ Not pregnanl within past year
<br />o pregn.nt allime 01 de.th
<br />o Nol pregnanl, bUI pregnant wlll1ln 42 days of dealh
<br />o Not pregn.nl, bul pregnanl43 day' 10 1 year before death
<br />o Unknown if pregnant within thA past year
<br />
<br />-;:I::::::T~::~: (Mr;~;' 'L.J;;;::::::::"
<br />
<br />
<br />DYES 0 NO
<br />----- - - ---
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />21a. MANNER OF DEATH
<br />~ Nalural 0 Homicide
<br />
<br />21 b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />IJ AccidentO Pending Invesligation
<br />
<br />DYES
<br />
<br />:tl NO
<br />
<br />o Pedestrian
<br />
<br />o Suicide 0 Could nol be determined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES ~ NO
<br />
<br />o Olher (Specify)
<br />
<br />220, PLACE OF INJURY-At horns, farm, Slreet) factory"office building., cor.strllcHlon ~lle. efr.. (Specl!y)
<br />
<br />CITY/fOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23.. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo., Dey, Yr.)
<br />9/12/06
<br />
<br />24b. TIME OF DEATH
<br />unknown m
<br />
<br />>-:i i:;
<br />.cg:>.:
<br />j~~
<br />o.CLc(~
<br />~ffi~~
<br />" :>.: =>
<br />.coo
<br />t2cro
<br />o ~
<br />uo
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />8:40 m
<br />
<br />
<br />23b. DATE SIGN"D (Mo., Day, Yr.)
<br />
<br />23c. TIME OF DEATH
<br />
<br />m
<br />
<br />23d. To the besl of my knowledge, death occurred al the lime, dale and place
<br />and duo 10 the c,".e(s) staled. (Slgnalure and Tille) .,
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />_L!...YES _ ~.~[J ~_ROBA.~~ UNKNOWN __ . ... 0 YES_ . .._IX N~__ _. Not ApplicableY_26a is NO 0 YES 0 NO..
<br />n NAME, TITL" AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONIOR'S PHYSICIAN OR COUNTY ATTORNEY) (Typa or Print)
<br />Sarah Carstensen, Deputy County Atto ney: 231 S. Locust Grand Island N
<br />
<br />
<br />28a. nEGISTRAR'S SIGNATURE
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" D.y, Yr.)
<br />
<br />SEP 1 4 2006
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