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<br />
<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 ORIGINALRECORJl ONFlI-E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/~~i:ffi!:7jON;",V'lHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. j:;~'c..,c":o;:.i~,-o
<br />
<br />DATE OF ~UANCE M.~~~ct!.R
<br />FEB J 7 200RASSIST,4N-iSrATEBE~t$TRAR
<br />LINCOLN, NEBRASKA 2 0 0 7 0 0 8 2 3 iigALf~AN~-c:~Z~~_!ji=R~tES
<br />
<br />
<br />- n___. .__
<br />
<br />\J
<br />
<br />
<br />STATE OF NEBRASKA - oEPAR~~~I[Fl~};;~NO ~U~~N:~~VI6E8-~IN~!'J~ANO'SUPPo~~(l6_ 213A2
<br />
<br />DECEDENT'S-NAME (First, Middle, La,t, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />--.1JJJian. Ru Terrill Female Feb-r;ui3.ry ~, 2006
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AG~-Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DAT~ OF BIRTH (MO., D.y, Yr.)
<br />(Yrs.) MOS. DAYS HOURS
<br />
<br />_.'1'haygr County. Nebra~ka
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />507 -14=-10,53."~_
<br />Bh ~..B,r.Il,ITY-NAMF (If n(~l 1~'i::ditl!IiQn. give strce: anr.l numhp.r)
<br />
<br />85
<br />
<br />
<br />1920
<br />
<br />6a. PLACE OF DEATH
<br />llilSElIAL:
<br />
<br />o Inpatil3nt
<br />
<br />Q:!IillJ: XJ Nursing Homa/LTC 0 Hospice Facility
<br />
<br />B~ve~ly Healthcare Park Place
<br />6c. CITY OR TOWN OF DEATH (tl1Glude Zip Codo)
<br />
<br />Grand Island 68803
<br />
<br />9~~:~:C:~T:E-- .' ----=1_ 9b~_;~~
<br />
<br />9d. STREET AND NUMBER
<br />
<br />1910,West_.1.J!=.h _Street
<br />lOa. MARITAL STATUS ATTIME OF DEAHi ~Marrled 0 Never MarriBd
<br />
<br />L_
<br />
<br />o ~~IOlltp8lient
<br />
<br />lJ DCGodeilU, riome
<br />
<br />o [l)\ 0 Other (Specify).
<br />--~ 8d. COUNTY OF DEAT, ,H
<br />Hall
<br />- ."~,,,._,_.,.
<br />gc. CITY OR TOWN
<br />
<br />Grand Island
<br />
<br />'---IP-T~1.f:~;C;~E3
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give moiden namo.
<br />
<br />9g. INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />o Merried, but separatod 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Ra uTe_rri11
<br />
<br />11. FATHER'S.NAME (First,
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Pearl
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Roberts
<br />
<br />Herma
<br />
<br />o Burial
<br />
<br />o Donation
<br />
<br />Not Emb.almed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />14b. RELATIONSHiP TO DECEDENT
<br />
<br />Husband
<br />16c. DAT~ (Mo.. Day, Yr. )
<br />
<br />February_.~, 2Q_Q~__.
<br />STATE
<br />
<br />NO
<br />15. METHOD OF DISPOSITION
<br />
<br />Terrip
<br />
<br />t6a. ~MBALMER.SIGNATURE
<br />
<br />16b. LICENSE NO.
<br />
<br />ID Cremallon I:l Entombment
<br />o Removal 0 Other (Specify)
<br />
<br />Westlawn Memorial Park Crematory
<br />
<br />Grand Island, NE
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Slate)
<br />
<br />fel Funeral Home 1123 West 2nd Street
<br />'"D .'1';
<br />
<br />
<br />17b. Zip Code
<br />
<br />68801
<br />
<br />PART I. Enter Ihe thai.n.~1s,--disaas8s, injuries, or complicatlons--that directly caused the death. DO NOT enter terminal events such as cardiac arrast,
<br />respiratory arrest, or ventricular fibrillalion wllhout showing Ihe etiology. DO NOT ABBRI:VIATI:. Enter only one cause on o line. Add additional lines if necessery.
<br />IMMEDIATE CAUSE:
<br />
<br />~YN w.,mQ(\;o...-
<br />DUE TO, OR AS A CONSEQUENCI: OF:
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />(d)
<br />
<br />I
<br />I
<br />
<br />I onset to doath
<br />
<br />:l~
<br />
<br />i-~~s;tto dealh f
<br />I
<br />I ~ V~-..v\-"}
<br />I
<br />I onset to death
<br />I
<br />I
<br />..1-
<br />I onsat 10 dealh
<br />I
<br />I
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />disease or condition resulllng
<br />IndeOlh)
<br />
<br />Sequentially list condlUons,lt (b) C \l f\
<br />eny, leading to the cause listed -.- DU~ TO, OR AS A CONSEOUENCE OF:
<br />on line a.
<br />Enterlhe UNDERLYING CAUSE
<br />(disease or Injury thet initiated (c)
<br />theeventsr.sultlng IndeOlh) DUE TO, OR AS A CONSEQU~NC~ OF:
<br />lA5f
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIDNS.Condltlons contributing 10 the death but not resulting in thB underlying cause given in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORON~R CONTACTED?
<br />
<br />LJ YES
<br />
<br />!M"NO
<br />
<br />20. IF FEMALE:
<br />~ot pregnant wilhin past year
<br />U Pregnant at time of death
<br />U NOl pregnant, but pregnant within 42 days of death
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />U Unknown If pregnant within the pas! year
<br />
<br />21e. MANNE OF DEATH
<br />alural 0 Homicide
<br />
<br />21 b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o AccidenlO Pending Investigation
<br />
<br />LJ pessenger
<br />I:l Pedestrian
<br />o Other (Specify)
<br />
<br />I:l YI:S
<br />
<br />~
<br />
<br />o Suicide LJ Could not be determined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUS~ OF D~ATH?
<br />
<br />DYeS
<br />
<br />~Q
<br />
<br />22a. DATE OF INJURY (Mo., Dey, Yr.)
<br />
<br />22b. TIME QFINJURY 22c. PLACE OF INJURY.At home, farm, street, faclory, olllee building, construction site, etc. (Spaclfy)
<br />m
<br />
<br />-22d INJURY ATWORK;-122a DESCRIBE HOW INJURY OCCURRED
<br />
<br />. U YES ~
<br />
<br />221. LOCATiON OF INJURY. STREET & NUMBER, APT. NO. CITY/rOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />uE'.ebruary .4 l
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />>j~
<br />-"~a:
<br />H~
<br />c. a.. ;,q: .::J
<br />5~j::i5
<br />"Ujz
<br />1lZ=>
<br />00
<br />~a:U
<br />815
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or Investlgalion. in my opinion death occurred at
<br />the lime, date and piece and due to Iha cau,a(s) stated. (Signature and Tille) ,.
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANT~D?
<br />
<br />DYES l\YN'0 PROBABLY CJ UNKNOWN 0 YES ~,-_Not Applicable if 26al, NO 0 YES Q"N0
<br />. 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNT-YATTOFiN~Y) (Type or Print)
<br />Dr. Ryan Crouch 800 N Alpha Grand Island, Nebraska 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo.. DBY, Yr.)
<br />
<br />tv
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<br />FEB 1 <1 2006
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