|
<br /> STATE OF NEBRASKA
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND. HUMAN SERVICES, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE&P0SM, ',0E1~P44q'T0ENT, OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F04 ,Vtj~k 0;0Rt $4'1.
<br /> DATE OF ISSUANCE x
<br /> SWEY S. COOPFR
<br /> DEC 14 2009 T,
<br /> M000413 A's,'I.STANT,SJATF, RE,GISTPM
<br /> D~PAR7 MTrYF JALTH ANh7
<br /> LINCOLN, NEBRASKA it A OES
<br /> _ HUIY~/1 N; SERVI
<br /> ti
<br /> STATE OF NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SEkVIC:S t
<br /> 1, DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX
<br /> P1f . P"Yii (MJ.nay,Yr.)
<br /> Sherri Lynn Dra a Female OGto,bbir 2 2OOD
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH ea AGE-Last Birthday 8b. UNDER 1 YEAR ac. UNDER DAY - 8 DATA OF'S PITH (ploi,. Day. Yr.) :
<br /> (Y-11 MOB. DAYS HOUR$ 'MINE.
<br /> Norfolk, Nebraska 42 June 7, 1967
<br /> 7, SOCIAL SECURITY NUMBER 80, PLACE OF DEATH
<br /> 506-04-6234 HQSPITAL: © Inpatient OTHER, ❑ Nursing Home/LTC ❑ Hospice Facility
<br /> ab. FACILITY-NAME (if not Institution, give street and number) ❑ ER/Outpatlent ❑ Decedent's Home
<br /> th and ad + t 06A ®Ol6erispecify)7th and K roads
<br /> 8c. CITY OR TOWN OF DEATH (Include 71p Code) ad. COUNTY OF DEATH
<br /> Chapman 68827 Merrick
<br /> On. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Merrick Cha man
<br /> 9d. STREET AND NUMBER Be. APT. NO. Of. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 1506 5th Road 88827 Yes ® No
<br /> 10a. MARITAL STATUS AT TIME OF DEATH W Married ❑ Never Married lob, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br /> [3 Married, but separated Widowed Divorced ❑ Unknown Darin Drage
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S.NAME (First, Middle, Maiden Surname)
<br /> Lester James Wra a Donna Darlene Kollmar
<br /> 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a, INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, No, or Unk.) N Darin Dra a Husband
<br /> 18. METHOD OF DISPOSITION 18a. EMB YMER-SIGNATUR 76b. LICENSE NO. 18c. DATE (Mo.. Day, Yr.) -
<br /> ®e.aal []Donation Lc n "D ~f.. / 43 9 7 October 6, 2009
<br /> []crematlon []entombment p
<br /> Removal ❑btheryepteify) 16d. C METERY, CREMATORY OR OTHER LO ATION CITY/TOWN STATE
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b, Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH See instructions and exam lea
<br /> tae PANT t. Enter the andn or events _ diseases, Irdudes, or rompacstlona. that directly caused the death. DO NOT enter termind events Ch a. eerdpe areal, t APPROXIMATE INTERVAL
<br /> respiratory a-at, or vemdcular fibrillation without .hewing the .Ilaloay. DO NOT ABBREVIATE. Enter only one cause on a Ilfie. Add additional line. R necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final
<br /> disease or condition resulting a)
<br /> In death) HEAD TRAUMA t
<br /> DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions, If
<br /> any, leading to the cause listed b) MOTOR VEHICLE ACCIDENT
<br /> on line a, DUE TO, OR AS A'CONSEQUENCE OF: t
<br /> , onset to death
<br /> Enter the UNDERLYING CAUSE c) '
<br /> t
<br /> (disease or Injury that Initiated
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: t onset to death
<br /> LAST t
<br /> t
<br /> d) t
<br /> t
<br /> 18. PART 11. OTHER SIGNIFICANT CONDITIONS-Condltions contributing to the death but not resulting In the underlying cause given In PART L 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> V YES NO
<br /> 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> Not pregnant within past year ❑ Natural ❑ Homicide
<br /> Zlprivar/OperelOr []YES 10 NO
<br /> ❑ Pregnant at time of death I, Accident ❑ Pending Investigation 0 Passenger
<br /> 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ❑ Not pregnant, but pregnant within 42 days of death ❑ Bulalda []Could not be determined Pedestrian TO COMPLETE CAUSE OF DEATH?
<br /> ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Other (Specify) YES Q NO
<br /> []Unknown if pregnant within the past year
<br /> 22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, alc. (Specify)
<br /> OCTOBER 2, 2009 2:20 P m 7TH AND K ROAD RURAL MERRICK COUNTY NEBRASKA
<br /> 22d. INJURY AT WORK? 22s. DESCRIBE HOW INJURY OCCURRED
<br /> []YES ®GJO MOTOR VEHICLE ACCIDENT BETWEEN TWO VEHICLES NEAR AN INTERSECTION
<br /> 22f. LOCATION OF INJURY • STREET R, NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br /> 7TH ROAD/K ROAD CHAPMAN, NEBRASKA 68827
<br /> 23a. DATE OF DEATH (Mo,, Day, Yr.) 2 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> $4 DECEMBER 8, 2009 2:25 P m
<br /> 23b. DATE SIGNED (Mo., Day, Yr.) 23c, TIME OF DEATH Q 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> }
<br /> g J$ m E y e OCTOBER 2, 2009 2:38 P m
<br /> aar
<br /> 2 CS 23d, To the beat of my knowledge, death occurred at the time, data and 1 at place W ~ 24e. On the basis of examimtlon and/or Investigation, In my opinion death occurred
<br /> 5 and due to the cause(s) stated. (Signature and Title) th tf,'Nd S UNgVe fSH nature and Title)
<br /> Sr
<br /> Bl p PAW`
<br /> 0
<br /> r ~
<br /> U o 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28s. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ❑ YES No PROBABLY 0 UNKNOWN YES ZI NO Not Applicable If 28a Is NO YES C1 NO
<br /> 27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br /> ANTHONY D MCPHILLIPS, MERRICK COUNTY SHER FF 1§21
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> DEC 10 zoo9
<br />
|