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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT pF HEAd.1~9 AI{I(Q~Ft''l/A!/}l~ ~'k~VICES; IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY pF THE ORIGINAL RECORD ON FILE WITH THE NEBRA~b~1P~7~P , '~NE~V7;K7~• i~J4L1~l-1 AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR' Vl`~,rlL.'f~ktD.~;1:; ,- ' -
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<br />DATE OF ISSUANCE ~~ ~„"~'_
<br />^~ QQ q 2 o i o o i 5 i i ~~~~~~ w~ -
<br />111a~ D a GO~~ A~S~AAM`~ i~G~STRAR °~
<br />DL~P~fi~EIVT O~ ~lE.4G~H A~~ ,'
<br />LINCOLN, NEBRASKA H(11(9A~:.§~~~~o., ~.'^hLS,
<br />STATE OF NEBRASKA-DEPARTMENTOFHEALTHANDHUMgNSERVICESFINANCEANDSUP ~ T ry
<br />CERTIFICATE OF DEATH - 4 (~~
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<br /> 1. DECEOENT'S•NANE IFirbl, Middre. uel. 5ulli:l 1 2. SE% ~. DAYEOF OEATN IMd. Da Yr.
<br /> Sharoa Kay Drahar y~sale Deca+~ber 5,lOb6
<br /> a. LITY AND STATE ORTERRITORY, OR FOREIGN LpUNTRY OF BIRTH 5a. ApE•Lasl BighdeY 56 UNDER 1 YEAR Sc. UNDER r pAY B.DATE OF BIRTH 1Ma., Day, Yrl
<br /> David Ci
<br />ty, Nabraaka IYri.l
<br />48 MOS. DAYS HOURS MINs.
<br />ootober 8, 1958
<br /> 7. SOCML SECURITY NUMBER 53, PUCE OF DEATH
<br /> 507-88-5962 HDSPITAt_ (~ Inpatient S~€R C7 Nurainq MamMTC ^HOSpice Facblry
<br />Q Bb. FAWLITY•NAME III not InaYlullOn, give atmel and number) ^ ER/Oulpelienl y~Decedenry HOmi
<br />~ 434 Kuaatars Lake
<br />x ^ DDA OOMd(Spce%y)
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<br />J BC. CITY DRYpWN OF DEATH pndude Zlp Cpdel BO.000NTY OF DEATH
<br />~ Arend Island 68801 Hall
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<br />9a.RE51DENCE•5TATE 90. CCAMTY fk, CTTY OR TOYYN .
<br /> Debraska Ha11 Grand Island
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<br /> 9d. STREET ANDNUMBER 9e. APT. NO 91. ZIP CODE Bp, INSIDE CITY LIMITS
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<br />e 434 ltneaters Lake 68801 ,~ VES ^ NO
<br /> 1pa. MARITAL $TATUS AT TrME OF DEATH X Marled Q Newr MAnied Ibb. NAME OF SPOUSE (Firer, Middle, Last Sulliq Ir wire, give meidM n.me.
<br /> ^ Married, but eeparaled ^ WidOwad ^ Divorced ^ Unknown Michael DrehBr
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<br />11 FATHER•5•NAME tpbp, Middp. Last, 5bNrq
<br />1Z. MOTkER'S•NAME (Fiat, Middle, Malden 5urnamel
<br />m Richard (DII~) HottoYry RoOe (PIIdI) Tvrdy
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<br /> 10. EVER IN U.5. ARMEDFORCE57 Glvi dabs 0l canto ll pi. Ha, INFORMANLNAME lab. AELATIDNSHIPTO DECEDENT
<br /> IYei. no, Or unh.( ETO Mlahaei Dreher Husband
<br /> 1S. METIIDD OF DISP05InON 16a EMBALM •SIGNq 18b. LICENSE Np. 16c. DATE IMp~. Dey, rr.(
<br /> )[BOHaI ^DenahOn 3 DACE~1'!Cr 9, 746
<br /> ^CNmalipn ^Empmbmenr 16d.CEMETERY, CREMATORY OR OTHER LOCATION CITYlTOWN STATE
<br /> ^Remdval ^Odterl5peCllyl Grand Island City Canetery, Grand island, Nebraska
<br /> 17a. FUNERAL HOME NAME ANDMAILIND ADDRESS (51net, Cily pr Town, Slalel 17b. Zip Coda
<br /> 1C1,aina Funeral HpTap, 3213 i~E Norkh 8'ronC et. , Grand Island, L+iS 68803
<br /> CAUSE OF D ATH (5Ba instructions and examples)
<br /> IB MRTLEnIer lbaytyyinMtienrs..di,eaaee, In~uriRS. br CempllCillpli•-Thal dhedlYCeYeedlM dNtN.00 NOT enter lermintl erenti Taco ai Cildlac unel, APPgpa1MATF INTERVAL
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<br /> reippatOry irresl, a wnrdduUr Ilbrillatgn w INbuI LneWlnq dla abddgy. DO NOT ABBREVIATE, Enur only onecauee On a EM. Add iddlta7rlal lino II naceaiary. l
<br /> IMMEDIATE CAUSE' ~ pmet lpdulh
<br /> ~ pulmonary embolism ' unknown
<br /> IMMEDIATC CADSE IF.yI
<br /> diMMeOrmlldelpnmWOlq DUE TO.OR AS ACONSEOUENCE OFD I pnurlp death
<br /> Yrdaatlt) I
<br /> s.RpandallynslCandlpam.R _~ pulmonary disease ~ unknown
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<br /> any,lndinarollN plM fNgd ...--......
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<br />DUE TO,ORASACDNSEQUENCfOF; r pnxllpeeam
<br /> do arN L I
<br /> Erdereti UNDERLYING CAUSE
<br /> (dMnwar lltlary dtN N1141W Icl '
<br /> ~e'~~pro~ln~l DUE TO,OR ASACONSEOUENCE OF~, 1 Onset tp dHlh
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<br /> 1s. PARY Ir.OTHER SIONIFK:ANT CDNDInDNS.GpndirionA eCmributlnq to Iha deals par sal resullinq In the ynderlylnq uuae glwn In PART I. 19. WAS MEDICAL EaAMINER
<br /> OR CORONER CONTACTE07
<br /> ~ YES ONO
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<br />W 20. rF FEMALE: 71a. MANNER OF DEATH 21b. IF TRANSPORTATIDNINJURY 71c. WA9 AN AUTOPSY pERFpRMLO?
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<br />~1 Npl pregnant within paalyur ~~YY~
<br />RrNamral ^ROmitiOa
<br />^OrivulDparNd
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<br />~ YE8 ONO
<br />~i ^ Pregnant at Ilene of deBIN O Accldam 7 Pending Iltwnlqulpn
<br />^Pawngn
<br /> Q Nol Ie nom, pal pro nom within a2 da f d death
<br />P 9 9 Y
<br />^5ulclde ^Could not be delermined ^ PedeetdAn 71d. WERE AUTOPSY FINDINGS AVNLABLE TO
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<br />'•J Nprpnpnam. but gegnanrgdaysroryru beMedesrh ^OIhu lSpecilyl
<br />COMPLETE CAUSE OF OEATHP
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<br />$ O Unanown it pregNnt rbhln 1N peM year x,] YES ^ NO
<br /> 22e. DATE OF INJURY IMo~. Day, Yr.l 22b. TIME OF INJURY 22c. PLACE OF INJURY•AI home. larm, Nreel. Iacrpry, b1fKe bulldog, canurlglipn slle. elC. tSpeciry)
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<br />~ 22d.INJURY AT WORK? 22e. DESCRIBE HaWINJURY OCCURRED
<br /> ^ YES ^NO
<br /> 721.1.OCATION OF INJURY •STREET6 NUMBER. APT.NO. UTY?OwR 5TNE ZIP CODE
<br /> Ida. DATEOF DEATH (MO~, Day.Yr.l ~ ~ 7N. DATE SIGNED IMO..4q. YId 7eb.TnAE OF DEATH
<br /> ~'aaa -- _ •- ---._.__.._~.~.. _ ~yx anuary .20,--204 -0310 ---m --~ --
<br />77o.DATESIGNED(Mp.,Day,Yc) 23c.TIMEOFDEATH ~,r~ 2at.PRDNOUNCEDDEADIMO.,Oay,Yr.l 2M.TIMEPRONfX1NCEDDEAD
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<br />o~ ~ m ~~`~~ December 5, 2006 0310 m i
<br /> 73d. TOIN besr at my rnpwledge, peeth OCCwwO at the Gene. date and pram ~ 2ie. On lhl bi51561 Raaminargn anNOr lnYNli9anprt,mmy Opmgn tleirh dCEUrNd el
<br /> E anOtlW ID TeHUS!(flSlifetl, (5lgnatWe and Tipe)r Bp Inetime, detund pla[Nnd ue lp lhecauAe(aJ slued. (SigNIuN aM Tlde]~
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<br /> ~ Futi all County
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<br /> 2S. DID TOBACCO USE CONTRIBUTE T07HE DE
<br />ATH? 26a. HAS pRGAN OR TISSUE
<br />DONATION BEER CONSIDEREDT 26h. Y~pdCONSENT GRANTED?
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<br />^ YES ^ ND ^PROBABLY GUN%NOwn ^ YES IT NO Ntl~l AppliCabll i176a 1i N0 ^ YE5 ~,.~ NO
<br /> TL NAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORgNER'S PHYSICuN OR C W NTY ATTORNEY) (Type dr gong
<br /> Mark J. Youn Hall Count Attorne 231 5. Locust Street Grand Island NE 68801
<br /> 2Ba. REGISTRAR581GNATURE 2Bb. DATE FILED SY REGISTRAR (MO., Oay. Vr,)
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<br />,,~!IJI~ rC'• 1, JAN 16 20Q7
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<br />HH5~1 11N3 (55061)
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