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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 COPY OF THE ORIGINAL R~90RD-_QfjFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlS}}ES_~E(;jiqji!"W#!CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.M_ _' =,__,j-__}fl-';___~;;~_'-_-.;,_>=~~/)f-~_:"'_:J'-~_:~_.._2-__~_'_~_'_.~_:~.
<br />
<br />DATE OF ISSUANCE ""'r;~~~ . . "-: ',-' \i
<br />MAR 2 4 ZOOb f =~: _-c'- ~y s.r:;.q,OPIiR
<br />A~$ISXANTSiAtt ~~/$ri:l4.~
<br />HEA.~ TH'4c.ND, HUM-4/t S;.RVlqf!S
<br />
<br />200707631
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOfrr u-' c 22--1- 2".' 0
<br />CERTIFICATE OF DEATHU _____
<br />____., ...."._n___._..,._____, .__
<br />DECEDENT'S.NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />~ A ~:?:_n Fffial.e Mm:h 12, 2C05
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Last Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />
<br />5e. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />NE
<br />
<br />~
<br />
<br />~_.~, 1955
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />aa. PLACE OF DEATH
<br />~J.l-',l'-'JAL'
<br />
<br />lIlrlf)!.Jli!-!r1!
<br />
<br />Q"llif,;B' i.J NlJr~iflg HomS!/!..TC U f ~:Jq;!:..;:,: f"i..:.:..;!!i!,'
<br />
<br />______ __ ~ 7.:2::1.584
<br />
<br />ab. FACILITY.NAME (II not Instllutlon, give streel and number)
<br />
<br />q ER/Oulpalienl
<br />
<br />q Decedent'. Home
<br />
<br />u [DI\ ~ Other (Specify) r -eJ lVM ~
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />E'a...md Ch.nty E'e-ard
<br />
<br />9a. RESIDENCE-STATE
<br />
<br />9b. COUNTY
<br />Lin:om
<br />
<br />
<br />91. ZIP CODE
<br />
<br />futxaSka
<br />9d. STREET AND NUMBER
<br />293) Ri.rdwxrl re.
<br />
<br />69101
<br />
<br />9g. INSIDE CITY LIMITS
<br />~YES UNO
<br />
<br />lOa, MARITAL STATUS AT TIME OF DEATH ~Marrled q Never M.rrled
<br />
<br />lOb. NAME OF SPOUSE (Flrsl, Middle, Lasl, Suffix) If wife, give maiden neme.
<br />
<br />U M.rrled, bul .eparalad q Wldowad q Divorced q Unknown
<br />
<br />J::e Pani.rez
<br />
<br />11. FATHER'S-NAME (First.
<br />
<br />Middle,
<br />
<br />Lastl
<br />
<br />Sulllx)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Violet I:bre€n 'Ib.rEke
<br />
<br />Middle,
<br />
<br />Maldan Surname)
<br />
<br />____~ ,J. _ AU:ers
<br />13. EVER IN U.S. ARMED FORCES? Give dates of servloelf yes. 14a.INFORMANT-NAME
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />m
<br />15. METHOD OF DISPOSITION
<br />
<br />q Burial q Donallon
<br />
<br />Billie ~
<br />
<br />I 16b. LICENSE NO.
<br />
<br />n/a
<br />CITY /TOWN
<br />
<br />16c. DATE (Mo" Day, Yr. )
<br />
<br />16a. EMBALMER-SIGNATURE
<br />
<br />IXCremallon q Enlombmenl
<br />
<br />rpt-~-.---
<br />15d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />March 15
<br />
<br />2006
<br />
<br />STATE
<br />
<br />q Removal q Other (Specify)
<br />
<br />Lin:01n
<br />
<br />
<br />Zip Code
<br />
<br />~."~ CmratoJ:y
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, Clly or Town, Stale)
<br />
<br />G:x'll:::erm11'-brtmry, ro B:lX 10 Gili:m NE
<br />
<br />la. PART I. Enler Ihe chain of evenla..diseases, injuries, or compllcallon'--Ihal directly causad Iha daalh. DO NOT enlar lermlnalevenls such as cerdlec arresl,
<br />resplralory arreSl, or venlricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Entar only one cause on a IIn9. Add additional lines if necessary.
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulllng
<br />In dealh)
<br />
<br />IMMEDIATE CAUSE:
<br />Severe Multiple Blunt Force Trauma of Head, Neck &
<br />(aj
<br />Trunk - .."."-~-
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on.ello dealh
<br />
<br />onset 10 death
<br />
<br />Sequentially lIst conditions, If
<br />eny, leading 10 the cause If Sled
<br />on line a.
<br />Enletthe UNDERLYING CAUSE
<br />(disease or InjUry thai Initialed
<br />the evanl. ra'ultlng In deelh)
<br />LAS!'
<br />
<br />(b)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsello dealh
<br />
<br />(d)
<br />
<br />~ Accidanlq Pending Invesllgallon
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />Q Drlver/Operalor
<br />
<br />~ Passenger
<br />
<br />Q Pedeslrlan
<br />
<br />Q Olher (Specify)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />Xl YES q NO
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS. Conditions contributing 10 Ihe dealh bul not resulllng In Ihe underlying ceuse given In PART I.
<br />
<br />20. IF FEMALE:
<br />CXNol pregnanl within past year
<br />q pregnanl al time of death
<br />q NOI pregnanl, bUI pregnanl wllhin 42 days of dealh
<br />q Nol pregnenl, bUI pregnanl 43 days to 1 year before deelh
<br />Q Unknown If pregnant wilhin Ihe past year
<br />
<br />21a. MANNER OF DEATH
<br />Q Natural q Homicide
<br />
<br />~ YES q NO
<br />
<br />q Suicide q Could nol be delermlned
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />Q( YES 0 NO
<br />
<br />22a. DATE OF INJURY (Mo" Day, Yr.) 2Jt TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, conslruction site, elo. (Specify)
<br />pprox m 1-80 Hwy
<br />- A Sf}--AM-
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />victim of Motor-vehicle accident
<br />
<br />CITYIfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />~8 _MilpM::!rkPT 368
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />S~\l1ar.d County--
<br />
<br />24a. DATE SIGNED (Mo.. Doy, Yr.)
<br />3-15-2006
<br />
<br />~~ffieEATH
<br />
<br />m
<br />
<br />m
<br />
<br />z>
<br />>:!!!l,!
<br />.ell",
<br />i"'~
<br />!l~::;
<br />E">Z
<br />8ffi!;;O
<br />llz=>
<br />~~~
<br />
<br />
<br />the time, dete and place and due to the caus
<br />
<br />.~
<br />
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />23c. TIME OF DEATH
<br />
<br />24c. PRONOUNCED DEAD JMo., Day, Yr.)
<br />3-12-200b
<br />
<br />23d. To Ihe besl 01 my knowledge, dealh occurred allhe lime, date ond place
<br />and due to Ihe cause(s) slated. (Signature and Title) ,.
<br />
<br />25. DID TOBACCO USE CONTRIBUTETOTHE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />: 27. ~A~:,~ITL~N~~DiiR~;6~6~~~FIER~P~;S~~I~:'~ORONER~ P:~~ICIAN OR COUNtfAT~~RN~YT (Type o;PrT~I)
<br />
<br />NO
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />MAR 1 6 200&
<br />
<br />~
<br />
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