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<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 ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sTATtgiics -$fiG:ii~_WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _':_00- '0'- "-~-:_~)C--:c- =~~'-
<br />
<br />DATE OF ISSUANCE ~.t~~ER
<br />
<br />AUG 082005 20080316 3 ~AsSJsTANTtnA"tE#l1$Gisi!RAR
<br />LINCOLN, NEBRASKA 1:fEALt,~ A~~~,:~~~_'J.~ijlCES
<br />
<br />..-
<br />. :".';: ~_"";i.,~~ :',=~ ~:-_-
<br />
<br />STATE OF NEBRASKA - DEPAR~~~~tF~~~;~N~t~~N;~~VICES FINA~~~{q's~J:t'-o~O 5 0 8 4 8 2
<br />DECEDENT'S'NAM~~~:~ .~~d~e, _____co~~~Ck _d SU;li;;;'--r;:nale- ~:~;-DrH (~Oo~5 Yr,)~ II
<br />4, CITY AND STATE OR TERRITORY, OR FOREHlN COUNTRY OF alRTH 5a_ AGE.Lasl Blrthd.y 5b_ UNDER 1 YEAR 5c. UNDER 1 DAY 6_ DATE OF BIRTH (Mo_, D.y, Yr.)
<br />Broken Bow, Nebraska (Yrs) 51 MOS DAYS HOUASLNS'- April 15, 1954 I
<br />
<br />I
<br />------\
<br />
<br />____ m
<br />
<br />e., PLACE OF DEATH
<br />
<br />~:
<br />
<br />o Inpallenl
<br />
<br />~
<br />
<br />o Nu"lng Homo/LTC 0 Hospice F.clllty
<br />
<br />8b, FACILITY-NAME (II nol Instllullon, glv. .lr..1 .nd numb.r)
<br />
<br />KI ER!Oulpallenl
<br />
<br />o Dec.dent'. Home
<br />
<br />Francis Medical Center E.R.
<br />
<br />Oro<l
<br />
<br />U Olh.r (Speclfy)____
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />Grand Island
<br />
<br />ed, COUNTY OF DEATH
<br />
<br />g., RESIDENCE-STATE
<br />Nebraska
<br />
<br />68803
<br />~. COUNTY
<br />Hall
<br />
<br />Hall
<br />
<br />Middle,
<br />
<br />gc,CITYORTOWN
<br />Doniphan
<br />
<br />. ---r'NO gl~~ ~o;~ ] gg,~s:~: CITY~M~;1
<br />
<br />lOb NAME OF SPOUSE (FI"', Mlddlo, Lasl, Sul1l.) If wll., glvo maiden n.me
<br />Terry M. Connick
<br />
<br />Suffl.) 12 MOTHER'S-NAME (Flrsl, Mlddl., M.lden Surnomo)
<br />Rose Fagot
<br />
<br />10., MARITAL STATUS AT TIME OF DEATH laMorriod 0 Novor M.rrled
<br />
<br />o M.rrl.d, bul..peral.d 0 Widowed 0 Divorced 0 Unknown
<br />
<br />11_ FATHER'S-NAME (F',"I,
<br />Wayne
<br />
<br />L..I,
<br />Kaps
<br />
<br />o Cremarlon 0 Entombment
<br />
<br />
<br />140, INFORMANT-NAME
<br />Terry M. Connick
<br />
<br />ill~C~N~E NO
<br />
<br />CITY /TOWN
<br />
<br />14b_ RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give d.le. of oorvlc.11 yo.,
<br />(n., no, 0' unk_) No
<br />f6, METHOD OF DISPOSITION
<br />IXBurl.1 CI Donellon
<br />
<br />16c. DATE (Mo_, Day, Yr,)
<br />Jul 11, 2005
<br />
<br />STATE
<br />
<br />o Removel 0 Oth.r (Speclly) Cedarview Cemetery - Doniphan Doniphan
<br />
<br />NE
<br />
<br />PART I. Enhn the ffi!!!.o.!l! evenls--dlseases, Injurlas, or compllcatlons.-that directly caused ttle dA~lh. 00 NOT cnlBr terminal events such as cardiac arrest,
<br />r..plralo'y ."esl, orventricul.r Ilbrlll.llon wllhoulshowlnglh. ""ology, DO NOT ABBREVIATE, Enler only on. causo on a line, Add .ddlllonalllnC5 II nec....ry_
<br />
<br />
<br />,
<br />I
<br />
<br />I onse110 death
<br />
<br />: LAl .
<br />_.J~...t'!1L.ft
<br />I on..llo dealh
<br />I
<br />,
<br />
<br />._----~-~,--
<br />I onoetto d..11I
<br />r
<br />
<br />17., FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, City or Town, Slalo)
<br />Curran Funeral Chapel 3005 South Locust
<br />
<br />Sequentlelly "" <ondlllon.,If
<br />.ny,leedlng 10 1110 <au..n..ed
<br />on tin..,
<br />E"* Ih/I UNDERtYlNG CAlISE
<br />(dI..... PI' Inturv IlIotlnltleled
<br />tll. ev.nto ",oulllng In d"",,,l
<br />LASf
<br />
<br />IMMEDIATE CAUSE:
<br />. i,'_, / ~ '
<br />
<br />,J-" . " /12- :1::4'
<br />~ tJ.~~v1<"._ Cf ..'lV'LI', _:_ ___
<br />
<br />DUE TO, OR AS A CONSEQUENC "F:
<br />
<br />~) 4('V:)lFJ~ 1LW \ . .... ~rJJ{L~~-
<br />
<br />DUE TO, OR AS 1. CONSEQUENCE OF: .
<br />
<br />IMMEDIATE CAUSE (l'1n0!
<br />d1_.. or condition res"'"ng
<br />In_II)
<br />
<br />(c)
<br />
<br />(d)
<br />
<br />I onsello d.olll
<br />,
<br />
<br />
<br />~----_.. 19'WAS MEDICAL EX-AMINER---1
<br />OR CORONER CONTACTED?
<br />o YES IX NO i
<br />21c_ WAS AN AUTOPSY PERFORMED?
<br />
<br />_ DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />PART II, OTHER SIGNifiCANT CONDITIONS-Condlflons conlrlbullng 10 III. d.ath but nol rosultlng In tile und.rlylng co us. given In PART '-
<br />
<br />21., MANNER Of DEATH 21b_IF TRANSPORTATION INJURY
<br />O N I I 0 H I Id ....Drlv.r/Op.ralor
<br />o Nol prognanl wllllln p..1 y..r · ura om c e ....
<br />o Prognonl gt 11m. 01 de.11I II AccldonlO P.ndlng Inv.sllg.llon 0 P....ng.r
<br />o Nol pr.gnant. bul prognanl wllllln 42 d.y. of do"1I 0 Suicld. 0 Could nol be delerminod 0 Ped..I,I.n 21d_ WERE AUTOPSYFINDINGS AVAILABLETO
<br />o Nol pr.gnan!, bul pr.gn.nt 43 days 10 1 y..r b.lore d.alll 0 Dlllor (Specify) COMPLETE CAUSE OF DEATH?
<br />~ Un~nownllprognanlwlllllnlll.p~s~y_~ar . _~:_~=- ---'?_!_~~ 0 NO ...
<br />220, DATE OF IN~RY (MO" D.y, Yr,) JUA\'. I ~o",o, lorn>,-<l"'o~ facto,y, 011100 building, con"rlJollon..llo, .to, (Sp.olly)
<br />
<br />~~d,JR~~W!#"- 220DESCRIBE:~W~JU~YOCCURRED rlVeri OS c'orilrol of vehicle & entered---North ditc-,
<br />x. 0 YES~NO ~hen over steered to tbe. hl efthcalI1e b.a.ck Qntotroqdw~. y crdossed c. ent.e~) ie,
<br />then over s teereil to rJ9J t ve 1 c Ie rpJl ed on 0 1 t .tup__rlYerJnec.:t~
<br />22t.LOCATION OF INJURY. STREET & NUMBER, APT. NO, CITYIfOWN ST!\[E ZIP CODE I
<br />,,"edge of the_driye way at 1570 north __Gt ltner Ro~d D.QniR_b_p,lL__~_E .. (),!3832j
<br />
<br />,~~:~T~ OFZ:~:~ ~Q';:y,y~ __ J e ~ iZ_4._~ DATE SI~.E_~-=O' Day, Yr.) _ 24b TIME OF D:~T:_~.u_nl
<br />
<br />23b. DATE SIGNED (Mo" Day, Yr,) ! ,.. ~ 24c_ PRONOUNCED DEAD (Mn" Day, Yr,) 24d, liME PHOI;()UNCCO DEAD
<br />
<br />Jul 21 2005 m 'H;o: ~ 111
<br />E&~Z
<br />23d. 8 w z 0 24B. On the basI!> olexaminBtion and/or Inv8stigallon, In my opinion dcalh occurred a\
<br />1] ~ 6 Ihe 11m., d.t. and place .nd due 10 Iho c.u.e(.) slal.d, (Signelure .nd Till. ) 'I'
<br />~a:C)
<br />8~
<br />
<br />20, IF FEMALE:
<br />
<br />DYES
<br />
<br />IJ[No
<br />
<br />26.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />2eb_ WAS CONSENT GRANTED?
<br />
<br />DYES 0 NO 0 PROBABLY jJ UNKNOWN 0 YES la NO .~~ Appllc.bloi'_~601" NO Q. \ES_lJl N()________
<br />2?, NAME, TITLE AND ADDRESS OF CERTIFIEfl (PHYSICIAN, coiioNER's PHYSICIAN OR COUNTY ATTORNEY) (Typ.-orP;i~~
<br />
<br />Steven G. Schneider Howardt Ste. 105 - Grand Island. NE 68803
<br />
<br />28., REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Gb, DATE FILED BY REGISTRAR (Mo" D.y, Yr.)
<br />
<br />AUG =. 3 2005
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