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<br />- i STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL ~ . FJIWA~IP;S`Ek~'"~CES, IT CERTIFIES
<br />THE BELOW TD BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA_ ~~RT,M N7' OF-HE~gLTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR •VITAt .RED©1Rb5. ~ ; .`` ;-,' ,f .
<br />DATE OF ISSUANCE
<br />AU G O ~ ZOD9 , sTANLEY S. APE ~ " : _. ;~
<br />~ASSIS[,4(VT A"~ ~~R,41~'
<br />LINCOLN, NEBRASKA ~ O ~ ~ O `-' ~ ~ ~ HUMAN SE~yI~ , ~HEALTH ANL~ r; ~'
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<br />STATE OFNEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOF~T',^© ~'~-~ ~^ •-y
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<br />1. DECEDENT'S•NAME (First, Middle, Last, Suffix) _ 2. SEX 3. DATE OF DEATH. (Mo., Day, Yr.)'
<br />Craig Lee Starke Male July
<br />26, 2009
<br />4. CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF 81RTH 5a. AGE•Lest 8irthdey 5b. UNDER 1 YEAR 5c. UNDER 1 PAY __
<br />e. DATE OF BIRTH (MV., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br />Williston, Nor1=h Dakota 37 JUl 7 1972
<br />7. SOCUL SECURITY NUMBER ea. PLACE OF DEATH
<br />' --1504 t14.SP,ITA~: Qlnpatient 9?f!~B~ ^NUrsing HOmelLTC UHospice Facility
<br />86. FACILITY-NAME (II not Inentutivn, give stre9t and number) ,y
<br />^ ERlOutpetlem ~? Decedent's Home
<br />Home; 3944 Hampton Rd.
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<br />_ ^ ~, ^Other (Specify)
<br />Bc. CITY OR TOWN OF DEATH pnclude Zlp Gode) Bd. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE•STATE 9b. COUNTY 9c. CITY pR TOWN ~~
<br />Nebraska Hall
<br />_ Grand Island
<br />9d.STREETANDNUMBER 9e. APT. NO 9f. ZIP CODE 9g.IN51DECITYLIMI7S
<br />3944 Hampton Rd. __ 68803 ~ Yes ^ No
<br />1ga. MARITAL STATUS ATTIME OF bEATHMarried ^ NBVef Merrietl igb. NAME OF SPOUSE (First, Middle, Lash Suffl%) If Wile, glue maiden name.
<br />^ Married, but separated 0 Widowed ^ bivCrced ^ Unknown
<br /> Tarr Starke
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix) 72, MOTHER'S•NAME (First, Middle, Maiden Surname)
<br />John Carl Garaas Eva Evans
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If yes. 14e.INFORMANT•NAME _R ~~ tab. RELATIONSHIP TO DECEDENT
<br />(Yes, no, Drunk.) No _ Terry Starke
<br />~ Wife
<br />75. METHOD OF DISPOSITION 189. EMBALMER•SIGNATURE 16b. LICENSE~NO. T 16c. DATE (Mo., Day, Yr, )
<br />~Burlal ^banation f July 30, 2009
<br />^Cremativn ^Entam6ment 18d.CE ERY,CREMgTORY ORO ER LOCATION CITYITOWN STATE
<br />^RemCVal ^Other(Specify) Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br />17a. FUNERAL HOME NgME ANp MAILING ADDRE53 (Street, Clty Or Town, State) _ ~ 4 ~ 17b. Zlp Code
<br />Apfel Funeral Home, 1123 West Second, Gx'and Island, Nebraska 68801
<br />18. PART I. Enter the chain of events--diseases, Injuries, or complications••that directly caused the death. DO NOT enter terminal events such as caPoiac arres4 ~ APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, or ventricular fibrillation without showing the stloldgy. DD NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines if necessary. I
<br />IMMEbIATECAUSE: I on9attodeeth
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<br />IMMEDIATE CAUSE(FInM _.(~ heart fd11UX'f~„_ ~
<br />1I11111P_f'~1r7tP
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<br />dlswwwcondnlCn reeuning OUE TO, OR As A CONSEQUENCE OF: I onset td death
<br />In death) I
<br />9.yu.nnapynatcondnldne,p (b) severe coroner heart disease Ilyears
<br />any, leading in the cause listed -"'.. - .. .,.. .,--..._----
<br />DUETO,ORASACONSEOUENCEOR I onset to death
<br />an nne a.
<br />ErderdteUNDERLYINGCAU8E I
<br />(dleaeseorln)urythatlnlttatad (°) I
<br />tfx,evsrdaraeultinglndeath) "~ - -._........---
<br />bUE T0, OR A8 A CONSEQUENCE OF: I On9et tv death
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<br />1 B. PART IL OTHER SIGNIFICANT CONpITIONS-Conditions contributing Id the death but net resulting In the underlying cause given In PART 1. 19. WA3 MEDICAL EXAMINER
<br /> OR CORONER CONTAC7ED7
<br /> X] VES © NO
<br />20. IF FEMALE: 21e.MANNER OF pEATH 21 b. IF TRANSPORTATION INJURY 21C. WAS AN AUTOPSY PERFORMED?
<br />^ Not pregnant wllhln past year ~ Natural ^ Hamlcide ^ DrlvarlOperaPor
<br />^ Pre nanl at time of death
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<br />Cl Accldent^ Pending Investlgalion Q Passenger YES ^ NO
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<br />D Not pregnant, but pregnant wllhln 42 days of death
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<br />^ gUlclde D Could not be determined
<br />© Pedestrian _
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<br />27d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />^ Nof pregnant, but pregnant 43 days to 1 year before death ^ Other (8peclly) COMPLETE CAUSE OF DEATH?
<br />^ Uhknown if pregnant within the past year ~ YES ^ NO
<br />a2a. DATE OF INJURY (Me., Day, Yr.) 22b. TIMe OF INJURY 22c. PLACE OF INJURY•At home, term, street, factory, ofnce building, conalructivn site, etc. (8peclfy) {T
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<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED l~ ~_~~.,.,,,..._.....~.-_
<br />^ YES [] NO
<br />22f. LOCATIDN OF INJURY -STREET & NUMBER, APT. N0, CRVROWN STATE ZIP CODE
<br />= 23e.DATEOFDEATH (Mo.,bey,Yr.) ~ 24a.DATSSIGNED (Mv.,Day,Yr) 24b.TIMEOFDEATH Between
<br />9~ ~'~ Jul 29 2009 1:3p am & lo:ooam
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<br />~ 236. DATE SIONED (Mo., Dey, Yr.) 23C.TIME OF DEATH ~ _ ~ 24c. PRDNOUNCEO DEAD (Mo., Day, Yr.) 2Ad. TIME PRONOUNCEb DEAD
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<br />~ m aaa~ Jul 26 2009 10:12 am
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<br />~ 23d. To the best of my knowledge, death occurred at the time, date and place
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<br />24e. On the basis of examinallon end/or investigation, in my opinion death occurred at
<br />and due to th
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<br />~ ~ B, dal and place td the cause(s) stated. (Signature end Title)
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<br /> De ut Ha11 Count Attor
<br />25.DIDTOBACCOU5ECONTRIBUTETOTHEDEATH7 26a.HA50RGANOF7IS5UEDONATIO NCONSIDERED7 266. WASCONSEN7GRANTED7
<br />^ YES ^ NO ©PR08ABLY ~ UNKNOWN ^ YES ~I NO Not Applicable i128a is NO C.I YES ^ NO
<br />Y7.NAMe,TITLEANDADDRESSOFCERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (TypevrPrlnl)
<br />Barbara Dunn, Deputy Hall County Attorney Office, 231 S. Locust St., Grand Island, NE 68801
<br />28a. REGISTRAR'S SIGNATURE /
<br />~ 2Bb. DATE FILED 0Y REGISTRAR (Mo., Day, Yr,)
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<br />arx. $..,5 aseris .,...,.
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<br />HHS-61 11/03 (55061)
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