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<br />~
<br />
<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 COpy OF THE ORIGINAL RECORD pH FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlr;.s.s~'2ItGJf;!4(jtICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~.' ~...~...,.:.:...~,"~,...~.:,..'.l".,~II~~i..';}.,
<br />
<br />DATE OF ISSUANCE - p.' '~"O
<br />~;,,~ f NLEY S~ coliPlR
<br />,JUN 0 6 2007 2007062 .. t A$IShtNt$tA~T:EoREGIStRM!
<br />LINCOLN, NEBRASKA ~ HEA!,TtlAND HUMA,isEFf\t1r:eS
<br />-.: - '=.. - ..~ ,- ;-
<br />
<br />
<br />- - ~_':' "'32"
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANC~'ANO'SUgpO T' .
<br />CERTIFICATE OF DEATH -.
<br />
<br />
<br />11-
<br />
<br />(Firsl,
<br />
<br />Middle,
<br />
<br />lasl,
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo., Day. Yr.)
<br />Ma 14 2007
<br />
<br />DGYid Cavana4gh
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH Sa. AGE-la.t Birlhday
<br />
<br />(Yrs.)
<br />
<br />5b. UNDER I YEAR
<br />MOS. DAYS
<br />
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />49
<br />
<br />ecember 19. 1957
<br />
<br />7. SOCIAl SECURITY NUMBER
<br />483-78-4778
<br />
<br />8a. PLACE OF DEATH
<br />J::lQSfTIAI.: IH Inpallant
<br />
<br />QIIJfB: 0 Nursing Home/lTC 0 Hospice Facility
<br />
<br />8b. FACllITY.NAME (If not In'lltullon, give streat and number)
<br />
<br />o ER/Outpallenl
<br />
<br />o Decedent's Home
<br />
<br />Lincoln
<br />
<br />o roo. 0 Othar (Specify)
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />
<br />Bryan West _
<br />Bc. CITY DR TOWN OF DEATH (Include Zip Code)
<br />
<br />68502
<br />--'-=-~~J 9b.coUNTYHall
<br />
<br />9d. STREET AND NUMBER 91. ZIP CODE
<br />
<br />9a. RESIDENCE.STATE
<br />
<br />
<br />9g.INSIDE CITY liMITS
<br />~ YES 0 NO
<br />
<br />3318 E SeedlingJ'1:Ll_~.J:~.d. 68801
<br />
<br />lOa. MARITAl STATUS AT TIME OF DEATH H! Married 0 Never Married lOb. NAME OF SPOUSE (Firsl, Middle, lasl, Sulllx) II wife, give maiden name.
<br />
<br />o Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Kristy J Bettes
<br />
<br />Middle,
<br />Cavanaugh
<br />
<br />Last,
<br />
<br />SuffiX)
<br />
<br />12. MOTHER'S-NAME ifirst,
<br />Claribel ~anders
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a.INFORMANT-NAME
<br />
<br />16a. EMBAlMER-SIGNATURE
<br />not embalmed
<br />
<br />16b. lICiNSE NO.
<br />n a
<br />
<br />14b. RElATIONSHIP TO DECEDENT
<br />wife
<br />M~yATBM,O, ~aMr7
<br />
<br />(Yes, no, Or unk.) . _". QQ_
<br />15. METHOD OF DISPOSITION
<br />o Burial DDonalion
<br />
<br />K~1~~Y J Cavanau h
<br />
<br />lXCremalion 0 Entombment
<br />
<br />I 6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY I TOWN
<br />
<br />STATE
<br />
<br />o Removal 0 Other (Specify)
<br />
<br />Lincoln Memorial Crematory
<br />
<br />Lincoln
<br />
<br />Nebraska
<br />
<br />17s. FUNERAl HOME NAME AND MAiliNG ADDRESS (Streel, Clly or Town, StBte)
<br />Curran Funeral Home, 3005 S. Locust
<br />
<br />NE
<br />
<br />
<br />PART I. Enter the c:hain...9~"diseasBs, injuries, or complicatlons--Ihat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiralory arrest, or venlricular fibrillalion without showing Ihe etiology. DO NOT ABBREVIATE, Emer only one cause on a line. Add additional lines II necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onsello deslh
<br />
<br />IMMEDIATE CAUSE (Flnal
<br />disease or condition mulling
<br />In death)
<br />
<br />Sequentlelly lI.tcondltlons, If (b) 5~IIt.t /";(';f(!I2I"rE
<br />any, leedlng to the ceuselisled - DUE TO;'DR AS A CONSEQUENCE OF:
<br />on line a.
<br />Enhlrtho UNDERlYING CAUSE
<br />(dl..es.or Injurythet initialed (c) lIt7llJ 1/lI./tlRf
<br />thee..nts re.uttlng in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LASt'
<br />
<br />(a) ~EA'E"/';?L cfJP'1I?
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I l"M,n
<br />._....__..1...__.
<br />I onset 10 death
<br />
<br />'I #4""S
<br />
<br />Onset to dealh
<br />
<br />,/4''''''$
<br />
<br />(d) /Jt~TJ)I'f'~tCtc 6C4S4t
<br />
<br />..___L
<br />I
<br />I
<br />I
<br />
<br />onset to death
<br />
<br />fAi?'#'5
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Conditions conlrlbutlng 10 Ihe desth bul not resulling in the underlying ceuse given In PART I.
<br />
<br />20. IF FEMAlE:
<br />[J Not pregnant within past year
<br />o Pregnant at time of death
<br />o Nol pregnant, bUI pregnanl wilhin 42 days of dealh
<br />o Not pregnanl, bUI pre9nenl43 days to I year before death
<br />Q Unknown if pregnant within the past year
<br />
<br />21 a. MANNER OF DEATH
<br />o Nalurel 0 Homicide
<br />
<br />19. WAS MEDICAl EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />L:J YES Ji!l NO
<br />
<br />21b.IFTRANSPORTATtON INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />aDrivBr/OpBrator
<br />
<br />BAccidenlD Pending Inv.sligallon
<br />o Suicide 0 Could not be delermined
<br />
<br />o Pes senger
<br />o PedeSlrian
<br />o Olhar (Spacify)
<br />
<br />DYES ]i( NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAIlABlE TO
<br />COMPlETE CAUSE OF DEATH?
<br />
<br />DYES
<br />
<br />~NO
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />_f:.(13/~ pd1
<br />
<br />
<br />22c. PLACE OF INJURY-AI home, tsrm. slrael, faclory. office buildin9, construction site, etc. (Specify)
<br />rIOME
<br />
<br />22e. DESCRIBE HOW INJ RY OCCURRED
<br />IJECEl/JElJ Opa"'?-J7N~
<br />_Ulr r;;r'/:C
<br />22t. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />22d.INJURY AT WORK?
<br />
<br />DYES JitNO
<br />
<br />flUJ/'PA'"CyctE b'l/ ~E I'Ya-'EiPTY, fiCCn&'}(",4/i!V"
<br />
<br />CITYIfOWN
<br />
<br />Sli\TE
<br />
<br />ZIP CODE
<br />
<br />3318 E. Seedling Mile
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />May 14, 2007
<br />
<br />Rd., Grand Island,
<br />
<br />NE 68801
<br />
<br />24a. DATE SIGNED (Mo" DBY, Yr.) 24b. TIME OF DEATH
<br />
<br />an
<br />
<br />:o~~
<br />aliiia:
<br />li?i:~
<br />Q;. CL ic( :::i
<br />~ffi~~
<br />1l~5
<br />t2a:(,,)
<br />o ~
<br />00
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />1:55
<br />
<br />24c. PRONOUNCED DEAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examInation and/or investigation. in my opinion death occurred at
<br />Ihelime, date and place and due to the cause(s) staled. (Slgnalu,e snd Till.)"
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />~
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />NOI Appllcsble if 26a is NO 0 YE;; ~ 0 NO
<br />
<br />So. 16th St.,Lincoln, NE68502
<br />28b. DATE FilED BY REGISTRAR (Mo" Day, Yr.)
<br />MAY 1 5 2007
<br />
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