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<br />STATE OF NEBRASKA
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<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL.. FI-t. ~iJiJ"~. SER.V.. ICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA$I:t!f'E:/E'PAR~'tpF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FORQYI~~~~lf€RO~~",.ii: 1
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<br />DATE OF ISSUANCE "', "'~'~
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<br />~ <~iZ~~' ~;g ... ~1:E~Af~~~
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<br />LINCOLN, NEBRASKA ',HI!.f1I.1N;SER'It."lS",.' ",I"
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMAN S~R~I~~~~ S ~1l:~f\:-:2i:31 0
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<br />FEB 2 0 2009
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<br />200901867
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<br />..u .J
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<br /> CEN' I'!-'LA . r- OF UFA' 'H ! . ' I '. '. ... ,',. )
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<br /> 1. DeCEDENrS~AME (First, Middle, Laet, Sulllx) 2. SEX ~.' DATE .OF ~'IIIO..Day,Yr.)
<br /> ."
<br /> 0" ~" ',or
<br /> Richard Georoe Decker Male Febril8'rv"8, 2009
<br />\ .. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 60. AGE.La.1 Blrthd.y 5b. UNDER 1 YEAR 5c. UNDER 1 DAY I. DATE OF BIRTH (Mo., D.y, Yr.)
<br /> (Yrs.) MOS. , DAYS HOURS I MINS.
<br /> Seward, Nebraska 74 July 24, 1934
<br /> 7. SOCIAL SECURITY NUMBER I.. PLACE OF DEATH
<br /> 505-36-3429 I:ISlIelIAI.; 0 Inp.U.nl ~O Nursing Hom./uc o Ho.pl", F.clllty
<br /> Sb. FACIUTY.NAME (If nolln.tilullon, give .....1 and number) IXI ERIOutpall.nl o Dlcidenr. Home
<br /> Saint Francis Medicai Center ODOA, o Otherj$pl<:lfy)
<br /> Ie. CITY OR TOWN OF DEATH (Include Zip Cacl.) lid. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> I.. RESIOENCE-STATE lIb. COUNTY 19c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> Id. STREET AND NUMBER '" h. APT. NO. 191. ZIP CODE ./. eg. INSIDE CITY LIMITS
<br /> 2018 Pioneer Blvd. 68801 151 Y.. 0 No
<br /> 10.. MARITAL STATUS AT TIME OF DEATH iii M.n1ed o N.v.r M.n1idl10b. NAME OF SPOUSE (First, Middle, L..t, Sufllx} " wIfe, give m.'d.n name.
<br /> o M.n1id, but '.p"'.tId 0 Widowed 0 Dlvorc.d o Unkn_n Jayne Bierman
<br /> 11. FATHER'S-NAME (First, Middle, La.t, Sufllx) 112. MDTHER'S.NAME (First, MIddle, MlIld.n SUrn.me)
<br /> Francis Decker Luise Scheumann
<br /> 13. EVER IN U.S. ARMED FORCES? GI.. d.le. or ....Ice "ye"I1... INFORMANT -NAME 14b. RI!LATIONSHIP TO DECEDENT
<br /> (Ye., No, or Unk.) No Jane Decker Wife
<br /> 15. METHOD OF DISPOSITION 11.. EMIIAlMER-SlGNATURE 1 15b. LICENSE NO. 11e. DATE (Mo., D.y. Yr.)
<br /> 081,,101 OD....Uon Not Embalmed February 9, 2009
<br /> IiiIC..mouon 0-"--'" 11d. CEMETERY, CREMATORY OR OTHER LOCATION STATE
<br /> 0"""...., OOUlotl.poclfy) CITYITOWN
<br /> Central Nebraska Cremation Service Gibbon Nebraska
<br /> 17.. FUNERAL HOME NAME AND MAILING ADDRESS (SIrs.t, City Ot r_n, S~te) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH (See Instructions and examples)
<br /> 1'. PART I. Enter'.... dwIn dawns. dl...... IpJur1ll. 01' con,plll;:adons- thai directly ".used the dt_h. DO NOT .....r wnnlnal ennt. ,ueh 8. .::_rd"l; _nit, : APPROXIMATE INTERVAL
<br /> respiratory anat, or yt~ul.r nb....lation without showing the .uo~lI'. DO NOT ABBftE'ltATL!Enter only one t::.u.. on . line. Add additional II,.. "nlc.,ury. I
<br /> IMMEDIATE CAUSE: I on..t to de.th
<br /> I
<br /> IMMEDIATEClIWSl!(_ -, '. I
<br /> dl..... or condlUon ",ulting ., massive injuries to the chest & abdomen a 'result of a , hours
<br /> In do.th) as I
<br /> DUE TO, OR AS A CONSEQUENCE OF: vehlcle pedestrlan COlll Slon : on..t to death
<br /> ,
<br /> SequenU.lly 11.1 condition., If b) I
<br /> Iny, I..dlng to the cause Uahtd I
<br /> on line .. DUE TO, OR AS A CONSEQUENCE OF: : on..t to d..th
<br /> I
<br /> I
<br /> Entot the UNDERLYING CAUSE c) I
<br /> (dl..... Dr Injury tIuot InlU.ted I
<br /> the eVln~ ...uIUn, In d..thl DUE TO, OR AS A CONSEQUENCE OF: I on.et to d..th
<br /> LAST I
<br /> I
<br /> I
<br /> d) I
<br /> 18. PART II. OTHER SIGNIFICANT CONDITIONS.(:ondltion. conlltbuUng to th. d..lh but not rs.ulllng In th. und.r1ylng c.u.. glv.n In PART I. 11. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> [lj YES o NO
<br /> 20. IF FEMALE: 2,.. MANNER OF DEATH 21b. IFTRANSPORTAnoN INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> o Nol pregnant within poet y..r o N.tural o Homicide o Dr1..rlOper.lor DYES []NO
<br /> o pregn.nt .1 Ume or d..lh 119 Ac.ld.nl 0 pending Investig.tlon o P....ng.r 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> o Not pregn.nt, but p..gn.nt wIthin 42 d.y. Of d..th o SuIcide o Could not be d.t.nnlnid GI P.di.trIen TO COMPLETE CAUSE OF DEATH?
<br /> o Not prs,n.nt but p..,n.nt 43 d.ys to 1y..r befors d..th o Oth.r (Spaclfy) DYES [lNO
<br /> OUnknown If p..gn.nt within the p..t y..r
<br /> 2210. DATE OF INJURY (Mo., D.y, Yr.) /22b. TIME OF INJURY 122.. PLACE OF INJURY-At home, f.nn, .trIIt, f.ctory, offIc. building, con.lrucllon .'te, .te. (Splclfy)
<br /> February 8, 2009 5:30 p.m. Blaine Street - gravel road
<br /> 22d.INJURY AT WORK? l22e. DESCRIBE HOW'INJURY OCCURRED
<br /> DYES CiNO descendent was struck by a vehicle oassino him on a ora vel road
<br /> 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
<br /> .Ill; irr 0. ...s..t.Jleet ' \-1/2. mi,l.a ,S,w tb ., 0 f Schil1lme r Rd)Graod. ls~-, ""''''~ N&:",-- .. '"' ~.~ ..
<br /> 23a. DATE OF DEATH (Mo., D.y, Yr,) !,~iZ _. DATE SIGNED (11'10.. Day, Yr.) 24b. TIME OF DEATH
<br /> Z
<br /> ~s: uz February 10. 2009 11 :05 n m
<br /> ,,!.! . r23c. TIME OF DEATH i iil:5
<br /> i~~ 23b. DATE SIGNED (11'10.. Day, Yr.) -~I:>- 240. PRONOUNCED DEAD (11'10.. D.y, Yr.) 2(d. TIME PRONOUNCED DEAD
<br /> ~~~ m to.o( ..J February 8. 2009 11 :05 P m
<br /> III ~
<br /> us 23d. To the best of my knowledg., d..th occurred at the tilM, date .nd place 8 ffi ~ 248. On the bal. of ex.mlnaUon and/or fnv..tig_Uon, In my opinion death occurred
<br /> ,2:-g and due to the c.u.e{.) .~ted. (Slgn.lura .nd Tltl.) 11 Z ~ ~ th. ume/1. ond pl.ce .nd due to th. c.u[j') .I.ted. (SI~n.I~" and TIll.)
<br /> 011 ~li!8 ~. eputy a 1
<br /> 1-0( 36 ( AJ""T; . ~ '\ Countv Attorney
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 12h. HAS ORGAN DR TISSUE DONATION BEEN CONSIDERED? 21b. WAS CONSENT GRANTED?
<br /> DYES ONO o PROBABLY 12!1 UNKNOWN DYES I!IJ NO Not Appllc.ble If 26e Ie NO o YES {] NO
<br /> 27. NAME, mLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORDNER'S PHYSICIAN OR COUNTY ATTORNEY) (Ty,", Dr pr1nt)
<br /> Sarah L. Carstensen, Deputy Hall County Attorney, 231 S. Locust St. , Grand Island, NE 68801
<br /> -. -- ~,., J. ~ 26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> 28.. REGISTRAR'S SIGNATURE
<br /> FEB 1 8 2009
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