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<br />STATE OF NEBRASKA
<br />
<br />.. WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AN]) #UMlJ.N-S~RVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINALBE90ROON-FILEWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISpc~ SEr;r.tg!J, WH/9H-!~
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~-,~t-~!_ j .:/1 ~,' \;','::'~~~
<br />
<br />DATE OF ISSUANCE ' , ,#. ,,-~, " :,
<br />M' AR 0 2 2007:- "', ,',', TA~LlNg,t:odptiFi~
<br />ASSiSTANT.STATEl!~/stRAj:
<br />HEAL TH.AND HUMM!-SEI!:IVICC$
<br />
<br />~
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />200803551
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH
<br />
<br />
<br />1. DECEDENT'S.NAME (FlrSI, Mlddl., LaSI,
<br />u_~Roger CIa Harp__
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa, AGE-Lasl Blrlhday
<br />Tulsa, Oklahoma ~~,) 58
<br />
<br />Sutll.)
<br />
<br />5b, UNDER 1 YEAR
<br />MOS, DAYS
<br />
<br />2,SEX
<br />
<br />Male
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />Febr
<br />
<br />
<br />.2001__
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />September 17, 1948
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />443-50-0307
<br />
<br />6b, FACILITY-NAME (11 nol inslitullon, give alre.t and number)
<br />
<br />6a, PLACE OF DEATH
<br />tlQ.S.fJlaL: 0 Inpatlonl
<br />
<br />lX ER/Oulpo1i.nl
<br />
<br />QIltiJ: 0 Nursing Homo/LTC 0 Hosplo. Faclllly
<br />
<br />o DocedonJ's Home
<br />
<br />Warren Memorial, 'Hos'pit al
<br />
<br />0[1)4.
<br />
<br />o Olhor (Spoclly)
<br />
<br />6c, CITY OR TOWN OF DEATH (Includo Zip Codo)
<br />
<br />Friend
<br />90, RESIDENCE-STATE
<br />
<br />6d, COUNTY OF DEATH
<br />
<br />9b, COUNTY
<br />
<br />68359
<br />9c, CITY OR TOWN
<br />
<br />Saline
<br />
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />
<br />-===~-Hil8South Harrison" street-.
<br />lOa, MARITAL STATUS ATTIME OF DEATH ~arrled 0 Nov.r Morriod
<br />
<br />Hall
<br />
<br />
<br />9g, INSIDE CITY LIMITS
<br />iJl YES 0 NO
<br />
<br />lOb, NAME OF SPOUSE (First, Middle, Leat, Suffl.) If wife, gllle maiden namo,
<br />
<br />o Married, but a.parat.d 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Carolyn Fillmore
<br />
<br />11. FATHER'S.NAME (Flr.t,
<br />Morris
<br />
<br />
<br />GIQ~_ia_
<br />
<br />Smith
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />Middle,
<br />
<br />Last!
<br />
<br />MOTHER'S.NAME (FI~I,
<br />
<br />Middle,
<br />
<br />Maldfiln Surname)
<br />
<br />13, EVER IN U,S, ARMED FORCES? Giv. dat.s of s.rvic. II yos,
<br />(Yes, no, or unk,) No
<br />15, METHOD OF DISPOSITION
<br />o Burial ODonallon
<br />01 Cr.malion 0 Entombmenl
<br />o R.moval 0 Olher (Specily)
<br />
<br />16b, LICENSE NO,
<br />
<br />CITY I TOWN
<br />
<br />16C, DATE (Mo" Day, Yr.)
<br />
<br />Feb..!.1,!lg:L~2 2007
<br />STATE
<br />
<br />1097
<br />
<br />Central Nebraska Cremation Service
<br />
<br />Gibbon
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, Clly or Town, Sial.)
<br />Curran Funeral Cmapel 3005 South Locust St
<br />
<br />PART l. Enter the chain of F.!vF.!nIR--dlseases, InJurles, or compllcallonsntha,t directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />resplr.lory arre.l, Or v.nlrlcular fibrillation wilhoulshowlng Ih. .tlology, DO NOT ABBREVIATE, Enlor only one cause on a line, Add .ddlllon.llln.. II necessary,
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (Final
<br />dlgeaSfl or condition r8sultlng
<br />Indelllh)
<br />
<br />(a) g/u~" / __Zivc. oe r ~,_....
<br />DUE TO, OR AS A CONSE~UENCE OF:
<br />
<br />S.qu.ntl'IIY lI.t conditions, "
<br />any,luadlng to the CllUSe listed
<br />on Ih;8,a.
<br />Enl.rth. UNDERLYING CAUSE
<br />(dl..... or InJUry Ih.1 Inlll'l.d
<br />the event. rasulllng In death)
<br />IA>f
<br />
<br />(b) ,I(b~.-- #<~~"'.F_!..l. c:o/;(..(....'.. ao--
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />ons.t to d..lh
<br />
<br />(c)
<br />
<br />..~,.,u,,~.~._..
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />onset 10 dealh
<br />
<br />(d)
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS-Condlllons contributing to Ihe deeth but nol r.,ulllng In Ihe und.rlying caus. given In PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES il!i NO
<br />
<br />20, IF FEMALE:
<br />o Nol pregnanl wllhln pa'l y.ar
<br />o progn.nl al time 01 deeth
<br />o NOI pregnanl, but prognanl wllhln 42 days 01 d.alh
<br />o Nol pr.gnan!. bUI pr.gnanl43 days 10 1 y.ar b.loro dealh
<br />o Unknown if pregnanl wllhln Ihe paSl year
<br />
<br />21a, MANNER OF DEATH
<br />o N.tural 0 Homicldo
<br />
<br />cJAccldenlO P.nding Inve.tlgallon
<br />
<br />ilb,lFTRANSPOATATION INJURY 210. WAS AN AUTOPSY PERFORMED?
<br />DO Drlver/Op.ralor
<br />
<br />o Suicide 0 Could nol b. d.lermlned
<br />
<br />o P....ng.r
<br />o P.daslrlan
<br />o Olh.r (Sp.clfy)
<br />
<br />o YES Xl NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />o YES 1& NO
<br />
<br />
<br />L~-/../--
<br />
<br />ft.c ....../
<br />
<br />C?""'P ~~ h',R /It ~yI/~--
<br />
<br />h4"-f- ~~n-..'
<br />
<br />22a, DATE OF INJURY (Mo.. Day, Yr,)
<br />;? ,/f'
<br />22d, INJURY AT WORK?
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY-At horn., farm, slrool, factory, olllce building, conalrucllon slle, elc, (Spacify)
<br />/f / S- m MM#369 Interstate 80
<br />
<br />221. LOCATION OF iNJURY. STREET & NUMBER, APT, NO,
<br />~1 ; k ,.#<,a .- .i:::...~ :> t:. "T
<br />23a, DATE OF DEATH (Mo" Day, YL)
<br />/ l' /c
<br />
<br />CITYITOWN
<br />J,:FO
<br />
<br />
<br />STATE ZIP CODE
<br />
<br />;1/r
<br />
<br />/b/$
<br />m
<br />
<br />~~~
<br />_II:
<br />iH
<br />c,a.. iI:( ~
<br />eg~~
<br />.8Z8
<br />,2~u
<br />8 ;;
<br />
<br />0" Day, Yr,) 24b, TIME OF DEATH
<br />
<br />m
<br />
<br />240, PRONOUNCED DEAD (Mo.. D.y, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On tho basIs of examlnatlon and/or Invesllgatlon, in my opinion death occurred at
<br />Ih.llme, date and plac. and du.lo Ihe cause(s) 51al6d, (Slgnatur. and Tille) T
<br />
<br />26., HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b, WAS CONSENT GRANTED?
<br />
<br />_,,_,9.__YES Q('NO 0 PR~BABLY 0 UNKNOWN .r:::J.YE_~ . Jil'NO ",,_ Not Appllcabl. 1126. I. NO _9 YES 0 NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (pHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />William Dailey, MD 905 - 2nd Street Friend NE 68359
<br />
<br />26a, REGISTRAR'S SIGNATURE 26b, DATE FILED BY REGISTRAR (Mo" Dey, Yr,)
<br />
<br />
<br />FEB 2 3 2007
<br />
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