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<br />� STATE OF NEBRASKA � - �'' �
<br />;
<br />! WHEN THIS COPY CARRIES THE RA/SED SEAL OF THE NEBRA3KA HEALF��UMAN $El�VICES
<br />y � SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE.QAIC�tLi�t�1f�HA1 FI� iN1TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM V1TAL �47-6�=i'1CS���QI �I/l�l�H IS .
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ ����
<br />DATE OF ISSUANCE r` r _ _- '
<br />{ ; _ �-= �Ai�+�y��330PER- '
<br />__-- JUN 2 3 2006 „ - Ass�sranrrsr,�r��c�sr��aA
<br />LIMCOLN ��BRas�► �,� 0110 6 4 4 5 t . ^ �I�AL�tf-�Gp-�A��v►LES
<br />_ -- �:�- �
<br />- - --. _�- ,
<br />STATE OF NEBRASKA- DEPARTMEN70F HEALTH AND HUMAN SERVICES FINANCE AND
<br />CERTIFICATE OF DEA�TH �
<br />y 1. DECEDENT'8-NAA9E (FIraL Mfddle, Leat, BuHixj 2. SEX 3.DATEOFDEATH (Mo.,Dey,Yr.)
<br />� •� A 1� F�[ale N� 12, 2q06
<br />� �
<br />& 4. CITY AND S7ATE OR TERRITORY, OH FOREIaN COUNTRY OF BIRTH 6a. AOE-Leat Birihday Sb. UNDER 1 YEAR 6c. UN�ER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />� (Yre.) MOS. DAYS HOURS MINS.
<br />9a. RE5IDENCE-3TATE Bb. CAUNfY 9c. CITY ORTOWN
<br />��S�g L7.YY��.I7 NC7L'�1 �.3�8
<br />Bd.STREETANDNUMBER 9e.APT.NO 81.ZIPCODE
<br />�ao � �. �ioi
<br />10a. MARITAL STATU3 ATTIME OF DEATH C�Marrled ❑ Never Merried 10b. NAME OF SPOU3E (First, Middle, Lasl, 3ufilxj It wHe, give maiden name.
<br />❑ Marrled, but sepereted ❑ Widoxred ❑ Divoroed ❑ Unknown
<br />�70E Fc�[02P.Z
<br />11. FATHER'S-NAME (FITSt, Mfddle, Lest, Suffix) i2. MOTHER'3-NAME (Flrat, Mlddle,
<br />�i�r .-r ni�,� �liolet Ibreg1 '�
<br />� � 50 NaVaiiber 4� �:9�5
<br />7. SOCIAL SECURffY NUMBER 8a. PLACEOF DEATH
<br />�� L� HOSPITAL: ❑ Inpalient Q� ❑ Nursing Home/LTC ❑ Hoapice Facllity
<br />Bb, FACILI7Y•NAME (If not InatNutlon, give street and number) ❑ EPl�utpatie�t Cl DecadenYaHame
<br />YTI�YS�.� � �@ � � ❑ D04 �(! Olher(SPecity) T�11 1VNf '3F�
<br />Ba CITY OR TOWN bF DEATH (Include Zlp Code) Bd. COUPdTY OF DEATH
<br />�a c�.y s�a
<br />t3. EVER IN U.3. ARMED FORCES7 Olve datea ot service fl yes. 74a. �NFORMANT NAME
<br />(Yes, no, or unk.) np Lij l l ie �
<br />15. MEfHOD OF DISPOSITION i8a: EMBALMER•SI6NATURE
<br />❑ euda� O omret�on xT7Dr flt�IiBd
<br />�Cremaflon ❑ Entambment 18d. CEMETERY, CAEMATORY OR OTNER LOGATION
<br />❑ Removal Q Other (3pacity)
<br />T �rm111 N$iC�]a� C�[EIYAY
<br />17a FUNERAL HOME NAME AND MAILINO ADDRESS (Street, City orTOwn, State)
<br />C��'Y�i^.q'7't T1¢7Y1'1F3YV. � B]X 1�. "�1. �'
<br />18b. LICENSE N0.
<br />CITY ! TOWId
<br />�•
<br />9g. INSIDE CITY LIMITS
<br />C� YE3 ❑ NO
<br />Maiden 9urnema)
<br />14b. RELATIQNSHIP T� DEGEDENT
<br />18c. DATE (Mo., Day, Yr. )
<br />March 15, 2006
<br />BTATE
<br />�.
<br />17b. Zip Code
<br />�
<br />18. PART I. Enter ihe �hein ai evenis--diseases, InJuriea, or compllceHona••that directiy ceuaed the deeth. DO NOT enier terminal evente such as cardlac arteat, APPROXIMATE INTERVAL
<br />I
<br />reapiretory eneat, or ventrlcular fibrilletlon without ehowing the etiology. DO NOT ABBHEVIATE. Enter only one ceuae on e line. Add addftfanai tlnes H necessery. �
<br />IMMEDIATE CAUSE: � onset ro death
<br />�Severe Multiple Blunt Force Tratuna of Head, Neck & ;
<br />numAEOw�causef�nei � m, � _ �
<br />dl�aseorcom�UonraulNng DUETO ORASACONSE�UENCEOF: I oneettodeath
<br />fn death) t
<br />I
<br />SequenUallyllstcomlftlons,M ro� I
<br />atry,leadingtathecauaeilated DUETO,ORASACONSEQUENCEOF: I onsettodeeth
<br />on Itrrea I
<br />EMerfheUNDERLYINQCAU3E I
<br />(dtseaseortnJurythattnidetad �°1 t
<br />theeventereaultingindealhJ DUETO,ORA3ACONSE�UENCEOF: � onaetWdeath
<br />� I
<br />�� i
<br />18. PART i�. OTHER SIONIFICANT CONDITIONS-CondlUone conhibutlng W ihe death but not reauidng In the under4ying cause g{ven In PAflT I. 19. VdAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED9
<br />�J YES ❑ NO
<br />20.IFFEMALE: � 21e.MANNEROFDEATH 21b.IFTRANSPORTATIONINJURY 21c.WA3ANAUTOPSYPERFORMED7
<br />�$Not pregnanl wiihin paet year ❑ Natural ❑ Homldda ❑ OdverlOperator
<br />❑ Pregnant at time of deeih �jAccidant0 Pendtng ImresUgaUon
<br />I�Passenger � YES ❑ NO
<br />❑ Nol pregnent, but pregnant within 42 days of death � P ����� 21d. WEREAU70PSY FlNDINOSAVAILABLETQ
<br />❑ Sutctda ❑ Could not 6e detsrmined � Other (Speciry)
<br />❑ Not pregnant, bul prepnant 43 days to 1 yeazbefore deaih COMPLETE CAUSE OF DEATFI9
<br />❑ Unknown R pregnant withln Ihe past year f� YES ❑ NO
<br />22a. DATE OF iNJURY jMo., Day, Yr.) 2?y.�TI JUR � 22C. PLACE OF INdURY•Athome, farm, street, oNice butldlrtg, conatmctton aiie, eta (Speclfy)
<br />'] 1']� 7(�/1G r,�_ �n �www . I �.� .
<br />22d.INJ�JRYATWORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />❑YES �aa Victim of Motor-vehicle accident
<br />22f. LOCATION OF INJURY • STREET & NUMBEA, APT, N0. C[TYlTOWN
<br />23a. DATE OF DEATH (Mo., Dey, Yr.)
<br />� 23b. DATE SIaNEO (MO., Dfly,Yc) 23c.111
<br />a
<br />r
<br />5
<br />a 23d.To the beat of my knowiedge, death occurted et the
<br />'e� and dua to the ceusa(s) steied. (Slgnature snd TB
<br />K
<br />25. DID TOBACCO USE CONTRIBUTETOTHE DEATH?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN
<br />27.NAME,TITLEANDADDRESSOFCERTIFIER (pHYSICIAN,C
<br />28e. REGI9TRAA`S 316NATURE
<br />S�UE ZIPCODE
<br />-- ------` --- -� 24a.DATESI�NEP (Mo.,Day,Yr.) ����m
<br />�,� � 3-15-2006 , m
<br />= DEATH . ���} 24c. PRONOUNCED DEAD Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m ��a 3-12-2006� pprox 8:30 AMm
<br />dete end place $�ii �� 24e. On the basis ot exeminedon andfor imestigetion opinion deatN occurred at
<br />�• .� �� ihe tim�ce end due to the caus ) s ed, (3igneture end Tftle )♦
<br />o�
<br />~�$
<br />28a. HAS OR6AN ORTISSUE DONATION BEEN CONSIDEAED? 28b. WAS GONSENT QRAN E?
<br />❑ YES NO Not Appllcable 1128a la N ❑ YES NO
<br />VER'S PHY9ICIAN OR COU ATTORNEY) (rype or Pdnt)
<br />��
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yc)
<br />MAR � 6 �006.
<br />0
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