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STATE OF NEBRASKA ~ ,~.~,:~w.~^~'c.~,,w ~ -
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANC4MaR~,S,ERa/.I.C''j?f~~ ??PI'ES`
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA D~AIFJ~NJgAt~1r~G~F~1~1~T~1~~FIVq~
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RE~pRdS~J
<br />DATE OF ISSUANCE
<br />06/02/2010 ~ o i o 0 4 2 ~ 2 STANLEY S: (ADpE~t ~ °`--" ~~ ` ~'°'` ~ ~" , ~,,
<br />ASSISTANIr"S1`AT~ REGdSTR>41R~' .' r~r~' _ '
<br />• t-; ,
<br />DEPARTMEl1~T ~~ AIV ~ ° "t" '
<br />LINCOLN, NEBRASKA HUMAN SERLdl~'E~'s ' • • ,~ F I ~_~':`~ • , ~'~~ ,'.. '
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES - (~ ~ /' ~ ~ I' ' 'r '`~. • a~~~ 509
<br />CERTIFICATE OF DEATH `~ ~~ ".
<br /> 1. DECEDENT'S•NAME (First, Middle, last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br /> Deborah Ka Dalland Female Ma 26, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY e. DATE OF 81RTH (MO., pay, Yr.)
<br /> (Yrv•) MOS. DAYS HOURS MINE.
<br /> Casper, Wyoming 52 September 18, 1957
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 505-78-9310 HOSPITAL ^ Inpatient 4ItIE6 ^ Nursing Home/LTC ^ Hospice Facility
<br /> Bb. FAGILITY•NAME (H not In;tltutlon, glue Street and number) ®ER/Outpatlent ^ Decedent's Home
<br />K
<br /> Litzenberg Memorial County Hospital ^ Doa ^ Other (Specify)
<br />~ 8c. CITY OR TOWN OF pEATH (Include Zip Code) 8d. COUNTY OF pEATH
<br />a` --Central City 68526 - - - - ---- - - Merrick -._ _
<br />J 9a. RESIDENCESTATE 94. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Merrick Central City
<br />LL 9d. STREET ANp NUMBER 9e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br /> 2720 S. 17th Ave 6$$26 ®YES ^ NO
<br />
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ^ Married ^ Never Married 10b. NAME OF SPOUSE (First, Mlddla, Last, Suffix) H wife, glue maiden name
<br /> ^ Married, but separated ^ Widowed ®Divorced ^ Unknown
<br /> 11. FATHER'S•NAME (First, Mlddla, Last, Suffix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br /> Donald Ray Mason Beverly Janice Rother
<br />°^ 1S, EVER IN U.S. ARMED FORCES? Give dates of service KYea. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yea, ND, Dr unk.) NO L nnette Marshall Sister
<br />,g' 15. METHOD OF pISPOSITION 16a. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />~
<br />r ®8urtal ^ Donatlan Laurie D
<br />Sheffield 1397 Ma
<br />201p
<br />29
<br /> . y
<br />,
<br /> ^ Cremation ^ Entombment
<br />
<br />^ Removal ^ Other (Specify) ied. CEMETERY, CREMATORY OR OTHER LOCATION CnY /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 /> A ATH ee instructions and exam les
<br /> 18. PART I. Enter the chain of events--dlasaaea, InJudas, or cgmpllnllons-that dlrocHy auasd the death. DO NOT enter terminal sventa such as Cardlpc arroat, APPROXIMATE INTERVAI.
<br /> naplrotory arrest, or vantdcular tibdllatlgn wlthqut showing the etiology. DO NOT A88REVIATE. Enter only one Huse on a Ilne. Add additional tines If necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Septic Shock ;Hours
<br /> dlsea-e or Condition resuMng
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Saquentlalty Ilst cpndhlona, If b) Infection :Hours
<br /> any, leading to the cause Ilged
<br /> on Ilna a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Entarthe UNDERLYING CAUSE ~) Quadraplegia ;Years
<br /> (disease or InJury that Inltland
<br /> the events reauaing In death) DUE TO, OR AS A CONSEQUENCE OF: I Onset to dsath
<br /> tASr d) Multiple Sclerosis ~ Years
<br /> 18. PART IL OTHER SIGNIFICANT CONpITIONS•COnditlons contributing to the death but not resulting in the underlying cause given In PART I. 18. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ^YES ®NO
<br />~
<br />w 0. IF FEMALE: 21 a. MANNER pF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED9
<br /> ^ Not pregnant within past year ®Naturel ^ Homicide ^ DrNar/Oparstgr ^YES ®NO
<br />~ ^ Pregnant at time oT death ©Accident ^ Pending Inveatigati0n ^ Passenger
<br />
<br />~+ ^ Not pregnant, but pregnant within 42 days of death
<br />^ Sulclde ^ Could not ba determinatl ^ Psdeatdan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />^ Not pregnant, but pregnant 49 days to 1 year before death
<br />^ Other (SpeclryJ TO COMPLETE CAUSE pF DEATH?
<br /> ®Unknown If propnant within the peel year ^YES ^ NO
<br />a
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, Street, factory, OfflCe building, Construction alts, etc. (Specify)
<br />s
<br />,~ 22d. INJURY AT WQRK9 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />~
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYl1"OWN STATE ZIP CODE
<br />
<br /> 23a. pATE OF DFATN (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> ~' W May 26, 2010 ~'
<br /> E ~ 28b. DATE 31GNED (Mo., Day, Yr.) 2Sc. TIME OF DEATH ~ ~ ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> $ i43 o June 1 2010 01:05 PM g ~
<br />~ ~
<br /> 9d. ro the beat of my knowledge, death occurrod at the time, date and place
<br />h
<br />l
<br />TI
<br />I
<br />~ $
<br />~ ~ 24e. On the bam of examination anwor Inwnigatlon, In my opinion death occurrod at
<br /> gnaturo and
<br />t
<br />a)
<br />and due to t
<br />e rauaslal stated. (S
<br />o + the time, den and place and due to the pussla) anted. (81gna[uro and TItl6)
<br /> ~ ~ Brian K. Buhlke, DO ~ ~ s
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 266. WAS CONSENT GRANTED?
<br /> ^ YES ^ NO ^ PR08A8LY ® UNKNOWN ^YES ®NO Not Applicable K 28a Is NO ^YES ^ NO
<br /> ype or rlnt
<br /> Brian K. Buhlke, DO, 2510 18th Avenue, Central City, Nebraska, 68826
<br /> 28a. REGISTRAR'S SIGNATURE ZBb. pATE FIIEp BY REGISTRAR (Mo., Day, Yr.)
<br /> June 1, 2010
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