|
:
<br />; �
<br />3
<br />7&PARTLENertlm ehalnMeverna-�.W�pee.mCOmPQeatiurm-1hetE�eUlycamedtlrodeath.DONOTe�effmmhmleveMSmehnemdiaearteaf.
<br />�nUe+�n+m�m.mtriemartmrmaUonr.�u�o�asnm,�ehe�oaexooNOraeat�rMreEmermurareauwonamre.Aadaaawona�wresu�. APPROXIAAATE(N'fERYAL ,
<br />IOAMEDUITE CAUSE: � onaet to deafh
<br />ieemenwre cause (�nm t � i
<br />61 D
<br />m�nj wnmacn�awas al _(��/"Vt L-oi - Ll,yl G�_r ,_ l
<br />DUE TO, OR AS A CONSECUENCE OF: a�ye� to death
<br />Sequenflaily Iist conAtlona, If b) �
<br />�f: le8ding to the cauBB➢�ed (
<br />on Ihre e. DUE TO, OR /64 A CONSEQUENCE OF: onaet ro deffih
<br />�
<br />F.Mer the UNDERLYINO CAUSE c) I
<br />(disease or Injury fhat INtlated
<br />��� �� � d�� DUB T0, OR AS A CONSE4UENCE OF: ' o�� � d�
<br />d) ' ' . � ' �
<br />7& PMT 0. OTHER SIGWFlCANT CONDITION3-Conditlo� contributing to the death but not reeWBng (n the imdertying cause gltren (n P/tRT L 18. WA8 AGEDICAL EXABIINER
<br />, ORCORONERCONTACTEDQ
<br />� .�e,i � ❑ NO
<br />W ��� 21a aAANNNER OF DEATH 216. IF TRAN8pORTATION INJURY 21a WAS AN AUTOPSY PERFORMEpT
<br />F �Nat pregnm�t witliln P� Year �Valuwt ❑ Homicide ❑ QrWerlOperaWr ❑ YES �ND
<br />� ❑Pregrrant et dme of deafh ❑ Acelde� ❑ Pendln8lnvastl9�on
<br />C� � P �� B � 21d WEREAUTOPSYFlNDING$AVAI� ew� c
<br />❑ Not PreB�eM. bu! PreB�� wifiiln 41 days ot deaR� ❑ SWclde ❑ CoWd mt be datamdned ❑ PetlesVlan
<br />� TO COMPIETE CAUSE OF DEATH?
<br />❑Na Pre9nent, bu[ pregnent a3 days to t Yaer betore death ❑ otlter (sF�YI
<br />� Ou�ow� u,,�n�uww,m m� a�er� �� � NO ,
<br />m
<br />a
<br />0 Z2a DATE OF pVJURY (dlo., Dey, Yr,) Z2b. TIAAE OF INJURY 2Ya, PLACE OF INJURY-At home. fertn, etreeq tactory, offtce puUding, eo�mtruoqw� �e. e�, (gpeeHy) .
<br />V
<br />d ' �
<br />m 2'Ltl. WJURY AT WORKT 22e. OESCRIBE HOW (NJURY OCCURRED ' .
<br />O �
<br />r ❑ YES ❑ NO . , • , , ' �
<br />� 22P. LOCATSON�dF ftd.lU.4Y - S'CSiEET & MUPlBEP, APT. Np. _ CITYlI91YN _ _, STATE 7JP COUE
<br />23a DATE OF DEATH (Mo., Cay, Yr.j � T4e. DATE SICiNE� (dlo., Dey, Yr.) 24b. TtlNE OF DEATH
<br />a� Januar 26 2008 , m
<br />� y� 23b. DA SIGNED Mo, Day, Yr.J T3c.'MAE OF DEATH g Y� 24t PRONOUNCED OEAD (670., Day, Yr.) 24d. TImE PRONOUNCED DEAD
<br />J /�
<br />E a � � �i8 � 3�� � ° �-
<br />a Y ►n Ema`'L m
<br />0
<br />� c � mfd du the� edge, demh xcurretl at the ti�, dete em! placa ���� 24e. On the 6asia M examinadon and/or Imeatl9�oM In my oplNon death oawrad
<br />) ateted. (Slgnatlue arW 77t1e) ,� Q O at Ure titoa, dete artd place m�tl due to the ceuse(s) etated. (Signeture end TIUe)
<br />� F a ,/ /K . `\ - t- � `o
<br />�✓
<br />26. DI� T09ACC0 �lSE CONTRfBUiE E DEATH4 Z6a. HAS OROAN OR T}SSUE DQMATION BEEN CONSIDERED9 28b. WAS CONSENT 6RANTED?
<br />❑ YES ❑ NO ❑ PROHABLY [�GNKNOWN � YE8 � NO NotAppltcabls If T8e ta NO ❑ YES ❑ NO
<br />27• NAME, TITLE AND ADDRESS OF CERTIFlER (PHYSICIAN, CORONER'8 PHYSICIAN OR COUNTY ATTORNEI� (Typa or Print)
<br />Travis Hagman, M.D., 729 iV. Custer A��e. Grand Island, Nebraska 68803
<br />zee. �oisrnaas s��nwTU� 2st,.. naTe Fl�o er �srRaR imo„ oay, rr.►
<br />P .. JAN � � 2008
<br />STATE OF NEBRASKA �
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHA��fUI�lAl�S�'Rll1�S `
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORICIAl�4! REGb�,d`tJ� FfL� UI7/TH ��
<br />THE NEBRASKA HEALTH AND HUMAN SERdICES SYSTEM, V/TAL STAT,lS'�7G��S�'�T%0J1� .1�Hl�H /S °-
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE :'��, `^�'�" K '
<br />�A� � � ���� �r��r��Y _y s
<br />2 01 �. 4 5 4`7 9 aSS���T��Q�� ����� r
<br />----- ElWCOl.�1(, NEBRASKA HE�f,i:FFI`dl�fl'ktLllfll!1�ACSEL��J�@5 :: '
<br />. � ?�?- 5 ' _ a ,1+'-= - �
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND�11JJ1lIAN;SE�'tVtC�S �y�� ����� p�
<br />C TI C E O D �, � C� ��
<br />1. OECEDENTSNAME (Flret, 6mddle� Lest, SutH:) _ t, 3. DA'f�`OF QEATH (INa.Day.Yr.)
<br />Leisa Ann Rohling `�'•�e I�i ,; � �Janua 28, 2008
<br />4. CITY AND STATE OR TERRITORY, OR FORflGN COUNTRY OF BIRTH Ba AGE-Last BlRhday 86. UNDER 7 Y�R ���. I� '` `� 8; pp7EGF BIRTH (Mo., Dey, Yr.)
<br />(Y►a) AA08. DAYS ` -H ;RA �-MIN$. - � �
<br />EI Dorado, Kansas 53 - October 31,1854
<br />7. SOCIAL 8ECURITY NUAABER 8e. PLACE QF DEATH
<br />0 508-66-7283 � 0�� �m�:0 ro�re Hom�n.TC H
<br />❑ o��e FeWacy
<br />V Bh FACIU7Y-NA69E (If mt IrrettttWtlon, gWe atreet m�d numberl ❑ EWOutPatleM �� � Dacedm�Y's Home
<br />� 4Q4 West 93th p noa Qar�lsa�r►
<br />0
<br />� ec cm oe rowN oF nearri �mcwae � caae� ea. cnunRr � neaTM
<br />Grand Island 68801 Hall
<br />` 8a RESmENCE-BTATE 96. COUNTY 9c. CITY OR TOWN
<br />LL
<br />�, Nebraska Hall Grand Is(and
<br />y� 8tl. STREET AND NUmBER 8e. APT. ND. 8/ 2Ip CODE 8g. INSIDE ClTY LIGAITS
<br />�, 4Q4 West 13th 68801 �C] Y� ❑ No
<br />� 10a AAARITAL STATUS AT TIAAE OF OEATH � AAartied � Nevaz Mertied tOb. NAME QF SPOUSE (Flraf, dtlddle, L�t, Suflix) It wjfe, gWe matden nema.
<br />� ❑ Merrfed, but sepawted O YYldowed ❑ Dlwrt:ed p u�a�o� Curt Rohling �
<br />o �' 11 FATHER'SNAME (Firek Mlddle, Lest. SuRbc) 12 dIOTHER'&NAAAE (Flrst, AAiddle, AAalden S�aname)
<br />S aname
<br />� Ha Gre ersen Ph Ilis Bruce
<br />m
<br />m 13. EVER IN U.S. ARd1ED FORCES? Ghe datea of service HYes. 14a WFORINANT•NAAAH 146. REIJlT10NSfUP 70 OECEDENT
<br />O
<br />� �r�, No, o. u�.� Unknown Curt Rohlin Husband
<br />16. METHOD OF O1SP0317TOPI ige, gpUISER.gt TU 18b. LICENSE NQ 18c. DA7E (INo., Day, Yt.)
<br />O� D��^ � � `j j' � Janua 31, 2008
<br />�� 0��
<br />O 0��, 18d. CEdIETERY. CREMATORY OR OTHER LOCATION q7YlTpWN STATE
<br />Centrat Nebraska Crematlon Service Gibbon Nebraska
<br />17a FUNERAL HOAAE NA6AE AND MAILING A11DRE$S (Sheet, CHy or Tovm, State) 176. ap Code
<br />All Fa�ths Funeral Home, 2929 S. Locust Street, Grand island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam les
<br />
|