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<br />.,.
<br />
<br />STATE OF NEBRASKA
<br />,~~, ", . .-
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDlm~.'~'1ICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REt!lJtfI'iBmS'WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/~~~SEi:ff&J,.~f;lIS'
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~....../l.~.:....-.'F. ~.':..~ ~~:-=.~-:ccl.'.'" ...-.._-~./I.".~.'.".'."'.~.:.-.~.;:.':.-.~~.'~.~..:-.:.,-.:..1,..~.;..~..'.'~;
<br />
<br />DATE OF ISSUANCE '., _p.:~I\--,-~~
<br />'= : fA1i1.IiY s.':c.cidRu
<br />L~~9LN~ N~B~~~kA 2 0 0 70 3 0 4 7 H~~~NT'STA~
<br />'~~W'~J
<br />
<br />
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEPND SUPPOR7
<br />.__._..._.._._._.~___. CERTIFICATE OF DEATH U
<br />
<br />21194
<br />
<br />1. DECEDENT'S.NAME (Flrsl,
<br />Paul D.
<br />
<br />Mlddla,
<br />Hassett
<br />
<br />lost,
<br />
<br />Sulllx)
<br />
<br />2,SEX
<br />Male
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr,)
<br />Janua~y 13,2007
<br />
<br />Lawrence, Kansas
<br />
<br />. '1'.5;;-~GE-LaSI-BlrlhdaY
<br />(Yrs,) 59
<br />
<br />5b, UNDER 1 HAR
<br />MOS, DAYS
<br />
<br />5c, UNDER 1 DAY 6, DATE OF BIRTH (Mo" Day, Yr,)
<br />HOURS[~=- December 28,194
<br />
<br />4, CITY AND STATE OR TERRITORY, 011 FOREIGN COUNTRY OF BIRTH
<br />
<br />7, SOCIAl SECURITY NUMBER
<br />
<br />
<br />'''PlACE OF DEATH
<br />I:lQSPITAl:
<br />
<br />o Inpatient
<br />
<br />,QlliEB: 0 Nursing Home/LTC 0 Hospice FBcility
<br />
<br />50_5 - 5 8:::DJJ11__
<br />FACllITY.NAME (If nol Institution, give street and number)
<br />Junction U.S. Hwy 281 &
<br />W Wood River Road
<br />
<br />Grand Island
<br />9a, RESIDENCE.STATE
<br />
<br />_n ] 9b COUNTY
<br />~ Ha 1 1
<br />
<br />r=ORTOWN
<br />Gra"l0 Island
<br />--.-- -- - t~' APT NO 01~C~D~ 1
<br />
<br />. - -...
<br />10b, NAME OF SPOUSE (First, Mlddlo, Lost, Sullix) If wlfo, givo maidon namo.
<br />
<br />o Decedent's Home
<br />~ Street
<br />o t:(l'. !HOthor(Spoclly) J("("i tl~~t..
<br />
<br />--I ad- COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />o ER/Oulpationl
<br />
<br />8e. CITY 011 TOWN OF DEATH (Includo Zip Coda)
<br />
<br />..N~hr_<i.eJS.fl__._.
<br />9d, STREET AND NUMBER
<br />3494 S. Shady Bend Rd.
<br />10a, MARITAL STATUS ATTIME elF-DEATH )f) Morriod 0 -N;v;;-;;rriad'~
<br />
<br />9g. INSIDE CITY LIMITS
<br />o YES IX NO
<br />
<br />o Marriod, but soparatod U Wldowad ODivorcad 0 Unknown
<br />
<br />11. FAHfER'S.NAME (Flrsl,' Mlddla,
<br />J,?sel2h~:_ Hassett
<br />
<br />Last,
<br />
<br />Rhonda Ringdahl
<br />
<br />SUfliX) 1;2'~O~~~~N~ME
<br />
<br />(Firsl,
<br />Kaiser
<br />
<br />Mlddla,
<br />
<br />Maidan Surnama)
<br />
<br />13, EVER IN U.S. ARMED FORCES? Givo dalas of sarvloalf yes, 14a.INFORMANT.NAME
<br />
<br />No David Hassett
<br />
<br />15~::~0~ OF DI:::r::::~ ~BAlME7JdWr- . -l~~:'ll~;N;.~N;:_"~n_._
<br />
<br />Q Cramatlon U Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />
<br />14b. RElATIONSHIP TO DECEDENT
<br />Son
<br />
<br />16c, DATE (Mo., Day, Yr.)
<br />1-17-2007'
<br />STATE
<br />
<br />o Removal o Othar(Spacily) Mount Hope Cemetery
<br />
<br />Valentine
<br />
<br />Nebraska
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Straot, Clly orTown, Stala)
<br />Sandoz Chapel of the pines
<br />
<br />Box 14
<br />
<br />
<br />18. PART I. Enlar the ~.s.--disea5eSj injuries, or complications..that dlreotly caused the death. DO NOT enter terminal events such as cardia.c arrest,
<br />respiratory arrasl, Or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines II necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onsotto doalh
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />Indeoth)
<br />
<br />
<br />Sequenllally li.1 condillons, II (b) aut om 0 b i 1 e co 11 i s ion
<br />
<br />any, leading to the cause listed ~~DUETO,- 6'Fi"AS A CONSE~UENCE OF: ~,~.,~.- ----
<br />on line a.
<br />
<br />w blunt force trauma to the head
<br />
<br />immediate
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsello death
<br />
<br />
<br />immediate
<br />onsal fo daalh
<br />
<br />Entar Ihe UNDERlYING CAUSE
<br />(disease or injury that Initiated
<br />the events resulllng In dealh) -
<br />lAST
<br />
<br />(e)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />1
<br />I onsollo daath
<br />1
<br />.1
<br />
<br />(d)
<br />
<br />_'''~''~M 7._'.""',~._,_
<br />18. PART II. OTHER SIGNIFICANT CONDITlONS.Condilions contributing 10 Iha death bUI nol rosulting in tho undorlying causa givan In PART I,
<br />
<br />20, IF FEMAlE:
<br />o Not prognant within pa" year
<br />o Pragnanl al tima 01 death
<br />o Not pregnant, but pregnant within 42 days 01 death
<br />o Not pragnanl, bul pragnanl43 day. 10 1 year beforo daath
<br />o Unknown II pragnant wilhln Iho past yoar
<br />
<br />21a. MANNER OF DEATH
<br />o Na.tural 0 Homicido
<br />
<br />19, WAS MEDICAl EXAMINER
<br />OR CORONER CONTACTED?
<br />.10 YES 0 NO
<br />21 b.lI; TRANSPORTATION INJURY 21 c, WAS AN AUTOPSY PERFORMED?
<br />~ Driver/Operator
<br />
<br />IXl AccldenlO Pandlng Invasligallon
<br />o Sulcido 0 Could not ba datermlnad
<br />
<br />o Passenger
<br />o Podaslrlon
<br />W Othar (Specify)
<br />
<br />c:J YES Xl NO
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES I.2(NO
<br />
<br />22a. DATE OF INJURY (Mo" Day, Yr,)
<br />January 13. 2007
<br />
<br />22b. TIME OF INjURY
<br />1: 48 P In
<br />
<br />22C, PLACE OF INJURY.AI homo, farm, straat, factory, oflice building, consfruclion slle, atc. (Spoclfy)
<br />street
<br />
<br />22d. INJURY AT WORK?
<br />
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />
<br />o YES 9 NO
<br />
<br />automobile collision
<br />
<br />221. LOCATiON OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CfTYlTOWN
<br />Gra_nd . Isl and
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />.J:lj bwa y 34/281 mil e ma rk~r 227
<br />
<br />NE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />
<br />z
<br />~::l
<br />J!~
<br />~~~
<br />E"-z
<br />8 g>o
<br />w:O
<br />'" c
<br />~~
<br />..
<br />
<br />m
<br />
<br />,..:Hi
<br />J:dj.;;!:
<br />iina:
<br />->~
<br />H<~
<br />E _"~ z
<br />0'" 0
<br />VuJ
<br />~z:>
<br />"'00
<br />~a:o
<br />o ~
<br />U 0
<br />
<br />--Ee
<br />24c. PRONOUNCED DEAD (Mo., DaR Yr.)
<br />January 13. 20u7
<br />
<br />
<br />pm
<br />
<br />23b, DATE SIGNED (Mo., Day, Yr,)
<br />
<br />23c, TIME OF DEATH
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />26a, HAS ORGAN OR TISSUE DONATIO
<br />
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />3: 00 p m
<br />
<br />23d. To the best 01 my knowledge, death occurred at the lime, date and place
<br />arid due to Iho ca.,sa(s) slalad, (Signature and Titia) "
<br />
<br />07
<br />
<br />o YES tJ NO 0 PROBABLY 0 UNKNOWN 0 YES ~ NO Not Applicablo if 26a i. NO IJ YES >u NO
<br />-----n:NAME:ili'l~ 'AND ADDRESS OF CERTIFIER (PHYSICIAN,66iioNER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />
<br />Michelle> J. Oldham, Chief Deputy Hall County Attorney 231 S. Locust Street Grand Island NE 68801
<br />
<br />26a, REGISTRAII'S SIGNATURE
<br />
<br />
<br />2Bb. DATE FilED BY REGISTRAR (Mo" Doy, Yr.)
<br />
<br />FE8 6 2007
<br />
<br />L~
<br />
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