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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN $fRVIGES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGFNAL RECORD ON FILE WITH THE NEBRASKA D�EP,�41��V� OF HEALTH p'ND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA�q�REC �5., �+� tl ;: .
<br />�
<br />DATE OF ISSUANCE , ,� •� �, � , .$ , r �
<br />03/01 /2012 ST�aNC�►; 's, oOPER �. � �j
<br />2 012 017 $'7 0� ��.�E� �H I ���'Q ;; �;
<br />LINCOLN, NEBRASKA Hf�N�N;SER�TC�Sd � ' �'
<br />cTe� ne uFaoss►ce _ neoeonueuT nG ueei Tu eun ui �nneu cFQintt:4`c :' '���.� .�'
<br />-••--- -• •---•--•-- --• ----•-•-•-• -• ••--••----- -------- ----��--e«- ,�.„.., • r. 7L UUbb3
<br />CERTIFICATE OF DEATH ;'� +�? '•. b'. �, �•,'m+"•' ,�
<br />1. DECEDENTS-NAME (FIBt� MIdd18 L.eSt� SYflIX� Z• SEX, �;� F i��� �•3, �� OR `DEAT'Fy (MO.� Dey, Yr.)
<br />Charles Gordon Robbtns Male `�±� ��• J(�ebruary 23, 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last BiRhday b. UNDER 1 YEAR Sc..UNDER 1 D'AY ' 8. DATE OF BIRTH (Mo� Oay, Yr.)
<br />(YB•) ' M03. DAYS HOURS IVON9.
<br />Long Beach, Califomia 72 April 27, 1939
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />505 �r� 4❑ inpaUer� rHe � Nursing HomaILTC � Hosplce Facllity
<br />Bb. FACILITY-NAME pf not InsUtutlon, gfve etreet and number) � ER/Ou�anent ❑ Decedem's Home
<br />�
<br />� Wedgewood Care Center ❑ ooa ❑ Other(Speclfy)
<br />� Bc, CITY OR TOWN OF DEATH (Inctude 21p Code) Bd. COUM'Y OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 8e. CRY OR TOWN
<br />w Nebraska Hall Grand Island
<br />�7 9d. STREET AND NUMBER 9e. APT. NO. 9L LP CODE 8g. INSIDE CITY LIMITS
<br />� 1703 West Charles 68803 � rES ❑ No
<br />� 10a. hMRITAL STATU9 AT TIME OF DEATH � Marrled ❑ Never Married 10b. NAME OF SPOUSE {Flraf, Middle, Last, SuHhc) H wHe, give malden �me
<br />� ❑ n�arrtea, nut separatea ❑ Wnaowea ❑ uNorcea ❑ unknown Edith V Rlemschneider
<br />m
<br />� 11. FATHER'S-NAME (First, Mlddle, Last, Suff�c) 72. MOTHER'S-NAME (Ftrst, Middle, Maiden Sumame)
<br />m Gordon Robbins Adrienne Isham
<br />E 73. EVER IN US. ARMED FORCES? Give datee of service If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yes, No, or unic.) No Edith V Robbfns Wife
<br />� 75. MEfHOD OF DISPOSITION 18a. EMBALMERSIGNA7URE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burial ❑ DonaUon
<br />Chris McCoy 1191 February 29, 2012
<br />❑ Crematton Q ErrtombmeM 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />� ���� � � (sp Shelton Cemetery Shelton Nebraska
<br />17a. FUNERAL HOME N1�ME AND MAILING ADDRESS (Street, Cily or Town, Sfate) 77b. Zlp Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructlons and exam les
<br />ta PnRi L Enmr the shaln oTevem� di�e, InJurtes. ar comppcadonadhet dtrectly ceueed the death. 00 NOT e�rter termina� evame sucn as cardlac artest, ; APPRO70MATE INTERVAL
<br />respUa�ry arteat, or ve�rtrlwiar flbrlllation wkhout showlnp the edology. DO NOT ABBREVIATE. Frrter ony orre cause on a Ma. Atltl aGdldo�ml Ilnee f( neeessary. i
<br />IMMEDIATE CAUSE ; o�et to death
<br />IldMEDIATE CAUSE (F7rta1 e) Debility Unspecifted - Progressive ; Years
<br />diaease or conaitlon rasultlng
<br />1O �� DUE TO, OR AS A CONSEQUENCE OF: ' onset to death
<br />s��nenr �� ��amo�a n b) Cerebral Vascular Accident � 18 Years
<br />eaY� leadinp to the cauee Ileted
<br />on ane a. DUE TO, OR AS A CONSEQUENCE OF: � orreet to death
<br />HMer Ure UNDERLYING CAUSE C � j
<br />(dleeaw or InJury thet InitlaOBd �
<br />ure e"8"t° ree�'tt�"e i" de�u') DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />� d) 1
<br />16. PART II.OTHER SIGNIFlCANT CONDITIONS-Conditlo� conWbuti� to the death but not r�ultl� In the urMerlying cause gNen In P/lRT I. 18. WAS MEDICAL EXAMINER
<br />Mypartension, Coronary Artery Disease, D(abetes OR CORONER CONTACTED?
<br />� ❑ ves p No
<br />W 0. IF FEMALH: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21e. WAS AN AUTOPSY PERFORMED?
<br />LL
<br />F � Na pre¢� Wnnln �e yee. � nwwrai � Ho��ae ❑ DrNerror�ere�or
<br />w � Preenant at n� m math ���� ❑ YES � NO
<br />V ❑ AeddeM � Pandinp tmeaGpaUon ❑
<br />� Not prepnent, bW prepnam wlthin 42 eaye oT eeath � Pedestrlan 27d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />'� Not prepnant, but prepnant 4s aays to 1 ��� ��� �� � d���� TO COMPLETE CAUSE OF DEATHI
<br />� year betore deaqi � Other (Specty)
<br />� � Unimmm if Pre9�etrt vWUn the P� Year ❑ YES ❑ NO
<br />m
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, Tarm, atreet, factory, oftice bulidl�, co�retruetion alte, ete. (Specify)
<br />�
<br />.S 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREEf & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIONED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� � February 23, 2012 ,� � �
<br />� E 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� 24c. PRONOUNCED DEAD (Mo, Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E U Z Februa 28, 2012 12:40 PM g�<�
<br />$ a� � . To tire 6est of my Imowtedge. death axurted at tlre tlme, dete and piace $� � 24e. On tlte 6aela Mexaml�mtlon and/or InveaUgatlon. In my opinlon death occurted at
<br />o� antl tlue to tlre m�ele) ateted. (Slpnature and Tltle) o o the tlme. detB and Place a�M due lo Ure muee(s) efated. (Slpnature and TfUe)
<br />~ Kimberiy A. Mickels, MD ~ g s
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED7
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOVYN ❑ YES � NO Not Applicable H 28a Is NO ❑ YES ❑ NO
<br />2. E, TITLE F TIFI (PHY ! R UN �(Type ar Prlrrt)
<br />Kimbe�y A. Mickels, MD, 729 North Custer Avenue, Grand �sland, Nebraska, 68803
<br />28a. REGISTRAR'3 SIGNATURE � 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr)
<br />February 28, 2012
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