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<br />~
<br />
<br />STATE OF NEBRASKA
<br />
<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 STATISTICS SECTION, WHICH IS
<br />
<br />:::~::~::::::;TORY FOR VITAL RECORDS. ~~ J'~lN '
<br />
<br />DEG 31 Z007 }Jvw'''7i~l~9l1(pOPER
<br />, AssIST~tm'j.Ti jiEGI$ffl,AR,
<br />LINCOLN, NEBRASKA 200 8037 1 0 HEAL~~~.~~M~~ s~w~,:!';,
<br />
<br />,_ ," ,1"1 ;(-- ]",' "
<br />"",, , i
<br />, --:;> . ",!!- ir ./'4..;L.,.f
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ~INi\bIC~ AND SUPPORT
<br />CERTIFICATE OF DEATH, 'e' ".0.;..> I
<br />1. DECEDENTS.NAME (First, Middle, lasl, Sultix) 2,' Si;~i 'J!~~.:"":' ~~~]{UAT~~Mo..Day,Yr.)
<br />Wilma Ellen Mulliqan Fem...:!,e. .;..~t:16, 2007
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE.Loot Blrthdoy 5b. UNOER 1 YEAR 5c. UNDER >l'~YI",o:~l!'('jFBIRTH (Mo.~ DOy, Yr.)
<br />(YIS.) MOS. DAYS HOURS MINS,
<br />
<br />
<br />:.
<br />
<br />
<br />St. Edward, Nebraska
<br />
<br />70
<br />
<br />De'camber 23,1936
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-42-3657
<br />
<br />ea, PLACE OF DEATH
<br />1:tO.Sf1IAL: . l"patl,"1
<br />
<br />anm Q NUIIlIlll Home/LTC Q HoIpiCt FaolUty
<br />
<br />8b. FACILITY.NAME (II "ot '"Slltullon, give strut a"d number)
<br />
<br />Q EAlOulpotlo"1
<br />
<br />o Decedenl's Hom.
<br />
<br />Saint Francis Medical Center
<br />
<br />8c. CITY OR TOWN OF DEATH (I"clud' Zip Cod.)
<br />Grand Island, 68803
<br />
<br />o [0\ 0 Other (Specify)
<br />
<br />8d, COUNTY OF DEATH
<br />Hall
<br />
<br />eb, COUNTY
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />eg. INSIDE CITY LIMITS
<br />. YES Q NO
<br />
<br />ed. STREET AND NUMBER
<br />809 S. Pine
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH KM.rri.d Q Never Merried lOb. NAME OF SPOUSE (Fir.l. Middle, Last, Suffix) If wife, give maide" oame.
<br />QMerrled,buu.p.rat.d QWldowed ClDlvoroed OUoknown Patrick H. Mulligan
<br />
<br />t 1. FATHER'S.NAME (First,
<br />Daniel
<br />
<br />Middle,
<br />
<br />Last,
<br />Cahill
<br />
<br />sumx)
<br />
<br />12. MOTHER'S-NAME (FirSI,
<br />Wilma
<br />
<br />Middle,
<br />
<br />M.ld.n suroame)
<br />Divis
<br />
<br />o Cremelion Cl Entombm."1
<br />
<br />
<br />14b_ RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glv. d.t.. of .ervlce If Y.'. 14..INFORMANT.NAME
<br />(Yes, no, or unk.) No Pa trick B.
<br />16. METHOD OF DISPOSITION
<br />!l:Burlel 0 Do".Uon
<br />
<br />18b. LICENSE NO.
<br />1092
<br />
<br />, 6c, DATE (Mo., Day, Yr. )
<br />Dec 19, 2007
<br />
<br />CITY / TOWN
<br />
<br />STATE
<br />
<br />QRemov.1 o Other (Specity) Westlawn Memorial Park Cemetary
<br />
<br />Grand Island, Nebraska
<br />
<br />17e. FUNERAL HOME NAME AND MAiliNG ADDRESS (Street, City or Town, Stele)
<br />Curran Funeral Chapel 3005 South Locust Street
<br />
<br />I! PART I. Ent.r the chain ot events--<li8eeses,I"Jurles, or oompllcello08-.that dlrec:tly c.u..d the death, DO NOT enter t.rmloal lVI"lS such a. c.rdlac arresl,
<br />r..piralory .rra'l, or ventricul.r libriUalio" wllhoulshowlng the ."ology. DO NOT ABBREVIATE. EOler only O"e cau.. on a 1I0e. Add eddillon.lllne.lt neoesa.ry.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />ons.' to daath
<br />
<br />(a)~O*
<br />
<br />10
<br />
<br />s
<br />
<br />
<br />ons.t to death
<br />
<br />SeqU8l1tlelly 1101 condltiOl1l, II
<br />soy, leading 10 the ",...1_
<br />on 1108 a,
<br />EnIorIheUNDERLYING CAUSE
<br />(dl..... or lojury th.t InIU_
<br />the..- ...ulUog '" deBfh)
<br />LASr
<br />
<br />(b) ?{'{)~ Co..~L ~\o...
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />s
<br />
<br />on..llo d .th
<br />
<br />
<br />(c) Corn
<br />
<br />\ qq 5
<br />
<br />onaello deelh
<br />
<br />(d)
<br />
<br />o Not pregnaol within pest year
<br />Cl Preenenl elllme 01 de.th
<br />Cl NOI pregne"t, but pregn."1 wilhin 42 d.y. ot d..th
<br />Q NOI pragnaol, bUI pregnant 43 d.y.lo 1 yosr belo,e d..lh
<br />o Unknow" it pregl18nt within the pasl yeer
<br />
<br />\-h"N
<br />N/A-
<br />
<br />H,6 clu-h\ ~\'\
<br />
<br />
<br />tx
<br />
<br />18. WAS MEDICAL EXAMINER
<br />QR OORONER CONTACTED?
<br />o YES !I: NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.CMdition. contributing to th. d.ath bUI not resuitlng In Ihe underlying C.U.I glv.n In PART I.
<br />
<br />Cl AccldenlO Pandl"g I"vesligelion
<br />Q Suicide 0 Could nol be dlt.rmlo.d
<br />
<br />21 b.IFTAANSPORTATION INJURY
<br />Cl Drlvsr/Oper.tor
<br />
<br />o P....nger
<br />
<br />o Pedeatilao
<br />
<br />Q Other (Specify)
<br />
<br />tf~
<br />
<br />Cl YES .NO
<br />
<br />~1..MANNEROFDEATH
<br />.Netural Q Homlcld.
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILASLETO
<br />
<br />COMPLETE CAUSE OF DEATH? " '\1"
<br />-Cl YEll Cl NO .~
<br />
<br />DYES ONO
<br />
<br />
<br />22.. DATE OF INJURY (Mo.. Day, Yr_)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY-AI home, Ilrm" atra.l, faClory, oHloo Iluitdiog, construcllon 811e. eto. (Specify)
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STArE
<br />
<br />ZIP CODE
<br />
<br />~3a. DATE OF DEATH (1.10" Dey, Yr.)
<br />\~t\q..01
<br />
<br />23b, DATE SIGNED (Mo.. D.y, Yr,)
<br />
<br />24.. DATE SIGNED (Mo_, Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />E~1:i
<br />I~~~
<br />..~z
<br />. zO
<br />1\15
<br />~i~
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />~4e_ 0" Ihe besl. ol...mi"alion Mdlor Inv.8Iigallon, In my oplnloo dealh occurred.1
<br />the lime, data sod pleca .nd due to the ceuse(s) el.ted. (Signelure and TIUe ).,
<br />
<br />25. DID TOBACCO USECONTRI8UTETO HE DEATH? 26e, HAS ORGAN OR TISSUE DONATION 8EEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />
<br />. Cl YES )s(NO 0 PROBABLY 0 UNKNOWN 0 YES K NO NOI Appllo.bloII 26e ia NO Q YES K NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSIOIAN OR COUNTY ATTORNEY) (Typ. or PrI"l)
<br />Kimberly A. Mickels Me 729 N. Custer AV, Grand I~land, HE 68803
<br />
<br />
<br />26b, DATE FILED BY REGISTRAR (Mo" Dey, Yr.)
<br />DEe '7 2007
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