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STATE OF NE6RASKA -
<br />WHEN TNIS COPY CARR/ES THE HAISED SEAL OF THE NEBRASKA HE'ALTH AND HUMAN $ERVICES
<br />SYSTEM, IT CERTIFI.E5 THE BELOW 1"O BE A TRUE CpPY pF THE OR/GINAL RE6OR��fILE���TI�l
<br />TME NEBRASKA HEALTH AND NUMAN SERVICES SYSTEM, VITAL STATISF�`_SEF,�7l(�AI,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS, �_ '
<br />DATE pF ISSUANCE N� ��
<br />AUG 0 9 2005 ' _� `���� C° ��
<br />2 01 a o 9� 0 4 a����,�s�����,���.�
<br />LINCOLN, NEBRASKA HE�4�1'li �J�fD. �it/�1�N'����
<br />-- - _=-- �--� . �. - -
<br />_ _ - 4 - , _;� ". ,
<br />EALTH AND HUMAN SERVICES FINANCE Al�lF}�91,If-?�� ry�.� ��
<br />� STATEOFNEBRASKA-DEpAR OF D�ATM i U
<br />1, oECEpENT'S-NAME (F�rst, Middle, Last, v Sufllx) ^ �2~3EX ' � �3 DATE��OFDEATH��Mo.,Dey,Yr.) �
<br />�I'�l�,S Pi __. QIaIl �._ 2��5 ............._
<br />4. CI7Y AND $TATE OR TERRiTORY, Ofi FOREIaN COUNTRY OF 61RTH Sa. AGE-Lesl Birthday 56. UNDER 1 YEAR Sc. UNOEp 1 bAY 8. DATE OF BIHTH (Mo., Qay, Yr.)
<br />(Yrs.) MOS. DAY3 HOUp3 MINS.
<br />Grand Island, Nebraska 50 March 7, 1955
<br />.Z �FCUa�,u,e,n�a--_� _ _ _ _
<br />� 505-74-7292
<br />Bb. FACILITKNAME (II not Instltutlan, give stree� end nurtlb9f)
<br />2. miles no th, 3 ittiles east
<br />o� Camstoc�
<br />__-..- _._.._.
<br />8c. CITY OR TOWN OF DEATH (Includa Zip Code)
<br />valley County, 16 miles west af Ord
<br />9a.pE$IOENCE•STATE � 96.COUNTY �
<br />1V�bx�a H all
<br />9d.5TREET AN� Nl1MBER T
<br />'i 025 �dorth rierulecly
<br />N09PITAL: 0 Inpatlenl
<br />❑ ERlDutpatlent
<br />4IJ� ❑ Nureing Home/LTC ❑ Hospice Fac�lity
<br />L] pecedenPa Home
<br />❑ oos, �QvmB��sPa�ny�rural hwv
<br />Bd. COUNTY OF �EATH
<br />Valley
<br />9c. CITY OR TOWN
<br />_Grand Isla
<br />� ee. APT. NO
<br />9�. ZIP CO�E
<br />ioa. MARITAL STATUS AT TIME DF DEA7H' � Manled Ll Never Merrled iDb. NAME OF 3POl1SE (Flrst, Middle, Last, Sulflz)11 wl1e, glve malden name.
<br />.� Marrled, but separeted ❑ Wldowed (.l �Ivarced ❑ Unknown
<br />_. .. ..-- - ..---..,
<br />� 11. FA7NER'S-NAME (Flrst, Middle,
<br />�..._ John ••-----.
<br />Sharpn Seyler
<br />Lasl, Suffix) 12. MDTHER'S•NAME (Flrst,
<br />lolan Vera
<br />13. EVER IN U.3. ARMED FORCES? Give dates of sarvlce I� yas. 14e. INFO S N r-r,nMn Nolan
<br />(Yes, no, or unk.) �� naxo
<br />15. ME7HtlD OF DISPO5ITION 16 9ALMER- IGNATUFE �
<br />CYiBUrlal ❑ Donelion �� � �, �`�
<br />U Cremalian ❑ Entombment 18d. CEMETERV, CREMATOpV OR OTHER LOCATION
<br />❑�amo�a� UO�her�Speclly) Grand Island City Cemetery
<br />17a. FUNERAL HUME NAME ANU MAILIN[i AI7�HE55 (5treet, City or iown, State)
<br />Curran Funeral Char�l 3005 South
<br />9q. INSI�E CITV LIMITS
<br />� VES U YU
<br />M�ddle, .� Maidan Surname)
<br />McCullou h
<br />14b. RELATION3HIP TO OpCEOENT
<br />spouse
<br />18b. LICENSE N0.
<br />953
<br />--- ................
<br />CI7Y / TOWN
<br />Grand Island
<br />i 6c. DATE (Mo., b�y, Yr. )
<br />�uly 21, 2005
<br />STATE
<br />Nebraska
<br />tYd�. Zip Code
<br />18. PART I. En1ar the chain of evenla••diseasea, inJurles, or compllcallons--thel dlreclly ceused tha dealh, 00 NOT anler terminal events such as cerdlec errest,
<br />respiratory arresl, or vantrlcular flbrlllallon wllhoW showlnp the ellology. b0 N07 A9BREVIATE. Entar anly one ceuee on e Ilne. Add additlonat Ilnes il necBssary.
<br />IMMEDIATECAUSE: �
<br />IMMEDIATE CAUSE (Final
<br />diseeee or condMlon reaulling
<br />In dea�h)
<br />Sequentlelly Iiet cpndlllone, II
<br />any, leading to the cause Ilsted
<br />on Ilne a.
<br />EnMr the �Nb�RLYIN6 CAUSE
<br />(d�eepae or In�ury �hnt Initlated
<br />tha evanta reaultlng �n death)
<br />I.AS�
<br />� Uri1CripWR
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />ro�
<br />bUE 7p, DR AS A CONSEQUENCE OF:
<br />(C)
<br />DUE T0, OR AS A CONSEpUENCE OF:
<br />18. PART II.OTHER SIGNIFICANTC ON�ITIONS�Condltions coniributing to Ihe dealh 6u1 nol resulting In lha undarlying causa givan In PART I.
<br />Injuries received �n a motorcqcle accident. Mr. Nolan was
<br />W�3r�Ilg g rtl�llpBt -_ ._._. ,.
<br />20. IF FEMALE: � 21a.MANN�q OF AEATH 216.1 7RANSPORTATION ItJJL
<br />❑ Nol preAnanl wllhin pasl year ❑ Netural � Homlplde �Ddvedoperato�
<br />❑ Pre nant at time ol death ❑ Passenger
<br />g �ACCidant� pending InvesNgallon
<br />❑ Pedealdan
<br />' APPROX�MA7EINTERVAL
<br />I
<br />I
<br />� onset to death
<br />I
<br />i onset to deelh
<br />I
<br />I
<br />I
<br />I onset ro death
<br />i
<br />I
<br />I ansel la death
<br />I
<br />1B. WAS MEDICAL EXAMINER
<br />OF CORONEH CONTACTE�1
<br />� VES "�
<br />�21c. WAS AN AUTOPSY PERFORMED7
<br />❑ Y65 xI N0� ,
<br />❑ Not pregnant, 6ut p�egnant wlthln /2 days of death O Sulcide O Could not be daterminad 27d. WERE AUTOPSY FINpINGS AVAILABLE TO
<br />❑ No1 re nam, but re nant 43 da s to 1 ear 6efore doath C,] Other (Speclly)
<br />P 9 P 9 Y 4 . COMPI.ETECAUSEOFDEATH7
<br />❑ l)nknown il pragnnnl wlihln Ihe past year � � YES 1�N0
<br />.,.., -,._ . _ �.--- -- - - -- - - --- , - � ._ i. _. .. . ,
<br />22a. DATE OF INJURY Mo., De , Vr. 22b. TIME OF INJURY 22a PLACE OF INJURY-At home, larm, streel, factory, olflce building, consiru,cllon ,
<br />( Y � site e�c. (Specity)
<br />July 16, 2005 Unknown"' �ao miles Noxtih and three miles East of Coms,tock,;
<br />22d. INJURY AT WORK7 22e. D@SCRIBE HOW INJURY OCCl1RRED ��
<br />❑ ves � r,o One vehicle �1Rp�OrCyClp� accident
<br />221. LOCATION DF INJURY - 5TpEET & NUMOER, APL NO. CfTY/�OWN STATE ZIP CODB AW
<br />Sargent road, ap�roxima�ely_16 miles West and 1 mile SoutY► of Urd valle County, :
<br />23e. DATE OF �EAtH (MO., oay, Yr.) _� 24a. bATE 310NE� (MO., oay, v�.) 246.TIME OF DEATH
<br />�'� n s Au ust 3 2005 Unknown m
<br />() '_'_-'_-�_' ' y LC '_
<br />r 236. bATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH . � r� 24c. PRONOUNCED DEAf] (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />�o m E� a� Jul.p 17, 2005 09:30 a.m
<br />9 23d.7o ihe 6es1 of my knowledga, death occurred e1 tha time, dele and plece & u� � 24e. On the basls of examinatlon andlor Investlgatlon, ln my opinlon dealh occurred al
<br />�� and due to ihe cause(s) slaled. (Slgnature and Tille )• o� U e tlme, date a d plece and due to ihe cause�s) slated. 3lgnature end 7itle )�
<br />"s o `�c.� � �` .(1�..,. V,:ob... (�n,v�. A��,e��
<br />i�
<br />25.DIDTOBACCOt13ECONTRIBUTETOTHE�EATW7 28a.HASOFiGANORTtSSUEbONA710N6EENCOf7$I�ERE�
<br />❑ YES _� NO ❑ pR09A9LY Q UNKNOWN U YES fJ NO
<br />27. NAME, TITLE AND ADDRESS OF CEFi7iFIER (PHYSICIAN, CoRaNER'S PMYSICIAN OR COUNTY ATTORNEY) (Type or Pr�M)
<br />Randy D. Cullers, Valley Count Attvrne , F.p. Box 40
<br />29a. qEGISTRAR'S SIGNATURE �
<br />�' t
<br />28b. WAS CONSEN'M1�f1ANTE(Xt,J
<br />No� Appllcable i� 26a is NO Q VES � NO
<br />O:rd, NE 68$62
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />Au� � s zoo5
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