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<br />STATE OF NEBRASKA
<br />
<br />~ WHEf/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 RECOR~-O,,! fiLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/SSjlEr;I!o/J<:~':' IS
<br />
<br />:::::::::C:TORY FOR V'TAL RECORDS ~!E~;j
<br />DEe 1 9 2005 ASStSTANTstAtEiREGI$TFlAR~
<br />200 90 12 32 HEALtHANp HpMAN $ERyi~~!
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />."_=,:.7~%:J
<br />
<br />
<br />STA.". E OF NEB. RASKA - DE. P...ARTMENT OF HEALT. H AND HUMAN SERVICES FINAf\I.. c~ ANQS. ..UPPGflT 0 5 13 8 3.2, _
<br />---..--__.___ . _., CE!HIFICATE OF DEATH, ..~_.. __
<br />1. DECEDENT'S'NAME (First, Middle, Last, Sufllx) 2, SEX 3. DATE OF DEATH (Mo" Day, Yr.)
<br />DIXIE A. O'NEILL FEMALE DECEMBER 7, 2005
<br />
<br />~ CITY AND STATE OR TERRITORY, OR FOREIGN C;UNTRY OF BIRTIHa, ~G-E-LaSl Blrlh~ay 5~~ U~DER t...Y., EA~' 5c. UNDER 1 DAY ~, DATE OF ~~~TH (Mo., Da~~~'
<br />(Y,",) M~DAYS HOUiiS.™TNS' JUNE 12, 1949
<br />GRAND ISLAND, NEBRASKA ______ :56_~_ ~
<br />
<br />ea, PLACE OF DEATH
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<br />7. SOCIAL SECURITY NUMBER
<br />506-60-8211
<br />
<br />1illWTAJ.:
<br />
<br />}b Inpatient
<br />
<br />QTI:JE8:
<br />
<br />CJ Nuralhg HomalLTC CJ Hospice Facllily
<br />
<br />eb. FACILITY-NAME (If not institution, give street and number)
<br />
<br />W ERIOutpationt
<br />
<br />o Decedenf'S Homo
<br />
<br />BRYAN WEST
<br />
<br />o IXl'I 0 Olher (Specify)
<br />
<br />,1~I~ ec CITY OR TOWN OF DEATH (Include Zip Cod e)- ... '~ISd' CO'lINTY. OF DEATH
<br />i' } LINCOLN, NEBRASKA 68502 LANCASTER
<br />
<br />Jt ~ 9a RESIDENCE-STATE ~NTY 'J9ZCI-iYORTOW.N - .- ,
<br />~ii' NEBRAS~A ~~~LL ~_ GRAND ISLAND
<br />It %' -9d STREETANDNUMBER -- - --- -- '-- I:' APT, NO 91,ZIPCODE -~SlIjECITYLlMITS
<br />t' I,,; 3108 KENNEDY CIRCLE 68803 ___L~ YES 0 NO
<br />
<br />t ,. ,~ """" "^w,^n"'O'-O~lli ~-"'"'" 0 ,,," """ /'" '^"' "'~"" ,,;~,: ",... "":."""" "'. ,;.. ",,,..;;''' - -
<br />, ~ DANIEL O'NEILL
<br />I', ~ 0 Married, bUI separated 0 Widowed 0 DIvorced 0 Unknown
<br />
<br />~t ";~~~';{;.~"' .'~~s;;- ~ ~ '",,,, Y;O'~~~;;;:" ","' ~;;'----.;;,;" ,","",,;,
<br />
<br />..!t~.p.~{ ~IN U.S. ARMED FORCES? G~;'service ilyesFie, INFD~MANT-NAME -- -- -- .- '14b, RELA;IONSHIP TO DECEDENT
<br />!~;\i!l: (Yes, no, or unk.) NO ----L- DANIEL 0' NEILL HUSBAND
<br />
<br />I" ;;:::O;"~:::: ';'~~'!i~ Ji211€,""---- ;i~;,~"iiho: 2~05
<br />
<br />.."-1.... DCrematlon o Enlombment 16d CEME RY,CR ORYOROTHERLOCATIO~ CITYITO~N ------s:rATE-
<br />
<br />
<br />o R.movel 0 Olher (Spacily)
<br />
<br />WESTLAWN MEMORIAL PARK CEMETERY
<br />
<br />GRAND ISLAND, NEBRASKA
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<br />17a. FUNERAL HOME NAM~ AND MAILING ADDRESS (Slr..I, City Or Town, St.te)
<br />ALL FAITHS FUNERAL HOME, 2929 S. LOCUST STREET, GRAND: ISLAND, NEBRASKA
<br />':.j "A':"'~":,,~'::;.,~:\-,:,::,,\ - ';~\'~;kij.t: ''''~.
<br />
<br />18. PART I. Enter the ~Y~"diseaoe., injuries, or complicatlons--Ihet dlractly c.u.ed the dealh, DO NOT enler terminal events such as cardlec erresl.
<br />respiralory arresl, or ventricular fibrillation withoul showing the .Iiology, DO NOT ABBREVIATE, Enler only one ceu.e on a line, Add additionalliM. if nec.s.ery,
<br />
<br />
<br />IMMEDIATE CAUSE: onsel to daath
<br />I
<br />~;fLtl-~i1a f-~---_______ ______:_ -~h,-,!r Jfmwl.
<br />
<br />DUE TO, OR AS A CDNSEQUENCE OF: I onsatto d.alh
<br />I
<br />
<br />: fr Ij~_
<br />
<br />I onset to death
<br />I
<br />I
<br />
<br />----~---------...__....
<br />I onsat 10 death
<br />I
<br />~ I
<br />
<br />1.B'. PA.RT II. OTHER SIGNIFI.C~A~IT CONDITI0'NS-condili~';;c~nlrlbUtin9..t~ I;' dealh.. b. ul n~1 re,ulting in Ihe undarlYln~ ce"i;gli.n .;~~---r.19~:A;~~~:. .Lc..~::.;~~::~
<br />
<br />_(t:r1f',"{':-t>-( J" it!>..... p.c../,.<< *jf!:!J/~{4Ci-'(4~, !fi1/bf' . ~~j,:,GYES _ D~_
<br />
<br />20.IF FEMALE: 21a, MANNER OF DEATH 21b, IFTRANSPORTA~~~JURY 21c, WAS AN AUTOPSY PERFORMED?
<br />~.. 0 Natural W HOm'ICidB 0 Driver/Operator
<br />ot pregnanl within past year ~O
<br />~ 0 YES
<br />O ~ 0 ,...cJ Passenger
<br />Pregnant al lime 01 doalh ,KJ Accidant Pending Invesllgation
<br />
<br />o Not pregnanl, bUI pregnanl within 42 days 01 death 0 Pad.slrlan
<br />o Sulcld. 0 Could not be detarmin.d
<br />o Nol pregnant, bul pregnanl43 days to 1 year before dealh 0 Other (Speclly) CDMPLETE CAUSE OF DEATH?
<br />
<br />o Unknown II pregnant within Ihe past year 0 YES 0 NO
<br />
<br />- 22a DAl EOF INJURY(Mo , Day, Yr) ~ TIM,E -OF INJURY 122c PLACE ClF INJURY-At hGm.~ 'arm, strool: laClor:.1-:-ulldm9, constru';lon site, elc (SPeCllY)
<br />
<br />~~O\t;~ t~$()~--_~,P1"/. 4.e "__ ,___.
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<br />22d INJURY AT WORK? 22e DESCRIBE HOW INJURY OCCURRED ~ , ,__
<br />
<br />DYES 0 NO f)1{~!" W'J.j #;/- ~,) , ! td.f(,~tJ/~,,! thJ./o ~11Y Iz~~.____
<br />
<br />221, LOCATION OF INJURY. STREET& NUMSER, APT NO, rTYITOWN STATE ZIP CODE
<br />NORTHWEST 112TH & WEST MCKELVIE OAD MALCOLM, NEBRASKA 68402
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />
<br />Sequantlallyllstcondltlons,1f -.!__::i..~",,,,'..e4z!_ ...~/".fl' yi1t.,z.d'.~ Wj/~' ", ____.
<br />.ny, I.edlng to tho oau.ell.ted DUE TO, OR AS A CONSEQUENCE OF: __
<br />on linea.
<br />Enterth. UNDERLYING CAUSE
<br />(di..... or Injury th.llnltiated (c)
<br />tho .v.nts ,e.ulllng In death)
<br />LAST
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />21 d, WERE AUTOPSY FINDINGS A V AiLABLE TO
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<br />23a, DATE OF DEATH (Mo" Dey, Yr.)
<br />
<br />~-O<('
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<br />23b, DATE SIGNED (Mo" Day, Yr.)
<br />-t)
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />m
<br />
<br />"'~~
<br />J:lOz
<br />lliii'"
<br />l~~~
<br />effi~~
<br />1l~5
<br />,2 a:: 0
<br />80
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
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<br />24e. On the basis 01 examination andfor investIgation, in my opinion death occurred at
<br />ths time, dale and place and due to Ihe cause(.) .Iat.d, (Signalura and Title) "
<br />
<br />25. DID TOBACCO USE CONTRI UTE TO THE D~ATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />,,-~?-~.,__ 0 PROB~B_~ U~KNOWN__~._._____ 0 NO _____. Nol Appllcableil 26a Is NO ..0 YES ~O
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSIC~~ SOftONER'S P!;IY's!l<IAN OR COUNT.1 arTORNEYLlT'yp~QI' eOn!) NE 68502
<br />REGINALD BURTON, M. D" 1..) Us. 1 bTH STRE~T, LINLUL1~,
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<br />2Ba, REGISTRAR'S SIGNATURE
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<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />DEe 1 3 2005
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