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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANp,#Il MAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG /NA'Lift -- QRC� ON .- rz _WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM , VITAL STATWICS ECT /ON, - - S il� IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE" FEB 2 2007 iANLEY S. COOPER LINCOLN, NEBRASKA 200706841 HEALTH AND HUMAN SERV ZS STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT CERTIFICATE OF DEATH -216- 7-3 ..- S fN 2 SEX 3, DATE OF DEATH (Mo., Day, Yr.) 1. DECEDENT'S -NAME (First, Mlddle, Michael Eugene Last, Cy-nova U X) ,ry a s Male January 27,.2.007 5a. AGE-Last Birthday 5b. UNDER 1 YEAR 60. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) _ 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH (Yrs.) MDS. DAYS HOURS MINS. Columbus, Nebraska 46 respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I October 20, 1960 IMMEDIATE CAUSE: ea. PLACE OF DEATH dQ.$NIAL: .Inpatient OTHER Cl Nursing Home /LTC L-1 Hospice Facility 7. SOCIAL SECURITY NUMBER 506730--4921 Bb. FACILITY -NAME (If not Institution, give street and number) "' IMMEDIATE CAUSE (Final (a) BLUNT FORCE TRAUMA _,�EDIATE ❑ ER /Outpatlent ❑ Decedent's Home disease of condition resulting DUE TO, OR AS A CONSEQUENCE OF: I onsettodeath t .tad 11 00A 10 Other (Specify)C011n� County_ Road- w- ._Willo Creek . -Road Bc. CITY OR TOWN OF DEATH (include Zip Code) ed. COUNTY OF DEATH _ er hey_. 691.43 Lincoln ga. RESIDENCE -STATE 9b. COUNTY 9c. CITY OR TOWN Nebraska Lincoln Hers 9d, STREET AND NUMBER 9e. APT NO 9f. ZIP CODE 6381 Wi11Qw.__ Cr-e1t.. oad 69143 1 oz. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Naver Married 10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name. ❑ Married, but separated J Widowed V Divorced ❑ Unknown N/A 11. FATHER'S -NAME (First, ME (First, Middle, _Ralph &Mlddle, Cgt1--ova Suffix) 2.MOTHER's•N^Bernice J. 13, EVER IN U.S. ARMED FORCES? Give dates of service If yes. 14a. INFORMANT•NAME (Yes, no, or unk.) NO Gary Cynova 15, METHOD OF DISPOSITION 16a, EMBALMER - SIGNATURE 16b. LICENSE NO. L1 Burial ❑ Donation Not - Embalmed 71 t b ent 16d. CEMETERY. CREMATORY OR OTHER LOCATION CITY /TOWN 99. INSIDE CITY LIMITS ❑ YES X1 NO Maiden Surname) Rohatsch 14b, RELATIONSHIP TO DECEDENT Brother 16c. DATE (Mo., Day, Yr.) February 2, 2007 STATE i glCrerrahon nom m ,ry a s Q Removal ❑ Other (Specify) Central Nebraska Cremation West Paxton Nebraska _. 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 176. Zip Code i, & Swanson Funeral Home P.O.Box 489 North Platte, Nebraska 69 03 -0489 Adams 18 PART 1. Enter the chain of eye •diseases. Injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as oardiac arrest, I APPROXIMATE INl'EF'vAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I IMMEDIATE CAUSE: onsettodeath C k•4 "' IMMEDIATE CAUSE (Final (a) BLUNT FORCE TRAUMA _,�EDIATE _ disease of condition resulting DUE TO, OR AS A CONSEQUENCE OF: I onsettodeath t 'A. in death) sequentially list conditions, It pT.nu yF.iT1,CL�AGf'TTIFNT ,;ry „•:.: any, leading to the cause Its ted' DUE TO, OR AS A CONSEQUENCE OF: I onset todeath on line 6. Enter the UNDERLYING CAUSE M .... the events result) gindeath)d - - -`�D) - - onset todeath UE T0, OR As A CONSEQUENCE OF: LAST EXAMINER 18. PART II, OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL }OR CORONER CONTACTED? C! YES U NO ra,.e 20. IF FEMALE: 21a.MANNEROF 216.IFTRANSPORTATIONINJURY 21o, WAS AN AUTOPSY PERFORMED7 6...' C3 Natural U Homicide IJ Driver /Operator ❑ Not pregnant within past year Cl YES X1 NO El �,� LI Pregnant at time of death 9 Accltlenlu Pending Investigation - UPedestrian 21d, WERE AUTOPSY FINDINGS AVAILABLE TO >' G Not pregnant, but pregnant within 42 days of death ❑ Suicide ❑ Could not be determined G Other (Specify) COMPLETE CAUSE OF DEATH? ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑YES NO L1 Unknown llpregnantwithln the past year ... 22a. DATE OF INJURY (Mo., Day, Yr.)) 2b.. TIME OF INJURY 22c. PLACE OF INJURY-Al home, )arm, street factory, office boiming, construction site, etc. ( Specify) JANUARY 27, 2007 COUNTX -ROAD WILLOW CREEK ROAD 22d.INJURYATWORK7 F221DJESCRIBE HOWI NJURY000URRED ❑YESXlNO LF COLLIDED WITH CONCRETE BRIDGE RAILING AND FLIPPED OVER 22f. LOCATION OF INJURY • STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE LINCOLN WILLOW CREEK ROAD C 9143 COUNTY NE 6,._.. I " 23a. DATE OF DEATH (Mo.. Day, Yr.) x Y 24a. DATE SIGNED (Mo., Day, L26 b.TIME OF DEATH BRUfiRY ] 5.m $'N Yr, 23c.TIMEOFDEATH '�'O 240. PRONOUNCED DEA(Md.TIMEPRONOUNCEUDEAP s J 23b. DATE SIGNED (Mo., Day, ) Ill na a TTl aZ ¢�o 23d.To the best of my knowledge, death occurred at the time, date O and place W z 24e. On the basis of examination and/or investigation, in my opinion death occurred at and due to the eause(s) stated. (Signature and Title) ♦ p O the Ilme, date and place and due to the cause(s) stated. (Signature and Title) T o� rM 25.DIDTOBA000 USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CO RED? 266. WAS CONSENT GRANTED? ❑ YES XJ NO ❑ PROBABLY U UNKNOWN ❑ YES t$ NO -._ 27. NAME, TITLE AND ADDREGS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Lincoln JIffers 1101A North Fla 28a, REGISTRAR'S SIGNATURE Not Applicable it 26a is NO ❑ YES U NO 28b, DATE FILED BY REGISTRAR (Mo., Day, Yr.) FEB 2 0 2007