|
STATE OF NEBRASKA � 41 � � 6� 1�
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />�HE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VI7"AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL R�EORDS '+ "+ {,
<br />r ,� .j., a ,,
<br />DATE OF ISSUANCE ��.��d���h �� i ' � J
<br />STANLEYs ..�CQIDPER � ;�• ",� `
<br />04/09/2012 ASSIS'T,,4AJT STAT�-REGISTRAR: • � �' ;
<br />�DEPA�2�J�I�Ni' p� H�ALTH„�ND �„ � r, _
<br />LINCOLN, NEBRASKA `HUMAt1�^��'RV�C;���, �=��, � � . ''�' , �
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC�S ��; '„' '�.' ,14 Al209
<br />CERTIFICATE OF DEATH . ` t-' - -�'r t ; �; . ; ` � ;' � "- --- -
<br />1. DECEDENTS-NAME (Firet, Middle, Last, Suffix), 2. SDC � °�, '3;'�AR,�('OF aPA7H (l�Ad ; Day; Yr.)
<br />Robert Selleck Bemis Male `' ,. '�' ' M��CP�"27; 20,12 ,-
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Laet BlRhday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH �o., Day, Yr.)
<br />(Y► MOS. DAYS HOURS ANNS. °
<br />Keamay, Nebraska 63 November 1, 1948
<br />7. IAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505-70-0827 OSPR ❑ Inpatlern OTHER ❑ Nurai� Home/1.TC � Hosplce FacIIHy
<br />8b. FACILITY-NAME qi not InsUtutlon, g(ve atreet arM number) � ER/OutpaUerR � Decedent's Home
<br />�
<br />� 520 Plum Road ❑ DOA � °��
<br />�a
<br />8c: CITY OR TOWN OF DEATH (inelude Zip Code) 8d. COUNTY OF DFATH
<br />o Grand island 68801 Hall
<br />� 9a, RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />Z 9d. STREET AND NUNBER . APT. NO. 8L ZIP CODE Bg. INSIDE CITY LINOTS
<br />� 520 Plum Road 68809 � ves ❑ No
<br />�.
<br />a 10a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Nevar Marrled 10b. NAMH OF SPOUSE (Firat, Mlddle, Last, Suffbc) B wHa, gfve rtmiden name
<br />a
<br />� ❑ mamed, bu� separaced ❑ v�ndowed ❑ Divorced ❑ unk�own ��� �th�ne Branson
<br />m
<br />� 11. FATHER'S-NAME (Flret, Middle, Last, Suffbc) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />� Robert Fowler Bemis Florence Barbara Selleck
<br />E 13: EVER IN U.S. ARMED FORCES? Ghe dates oi servlce R Yea. 14a. INFORMANT•NAME 14b. RELATION9HIP TO DECEDENT
<br />$ res, No, or unic.) No Laure Cathrine Bemis Spouse
<br />,� 15: METHOD OF DISPOSITION 78a. EMBALMERSIGNATURE 16b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� ❑ eunai ❑ normeon Not Embalmed ' March 28, 2012
<br />� Crematlon ❑ EMombmeM 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Remorai ❑ Other (SpeelTy) �ntral Nebraska Crema�on Services Gibbon Nebraska
<br />178. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Shte) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructlons and exam les
<br />1& PnRT I. Frrterthe chafn otava�di�asee, InJuriea, w compuraHOnsdhat dlrediy caused the death. 00 NOT emer mrminel eveNe auch as caNiac artest, ; AppROXINL4TE INTERVAL
<br />respUatory erteat, or ve�rtHwtaz flbralatlon wMhout showing the edology. DO NOT A69tiEV1ATE Fster ony o�re muse on e flne. Add adtlitlonal Onea H neceseary.
<br />IMd1ED1ATE CAUSE: ; o�et to death
<br />,�„� a)Cirrhosis, Non-alcoholic With L1ver Failure � Years
<br />disaase or aondttton resuUing
<br />� d �'� DUE TO, OR AS A CONSEQUENCE OF: � a� � d��
<br />se���uauy n�s �o�nmre, �r b) End Stage Renat Disease : Years
<br />aqy, leatling to the cause Ilated '
<br />� �� �' DUE TO, OR AS A CONSEQUENCE OF: ; orreet W death
<br />�u,euNO�nmacauae c)IschemicCardlomyopathy E Years
<br />(tlisease orinJurythetlnitlatetl �
<br />��"�'�"e �' �'� DUE TO, OR AS A CONSEQUENCE OF: : o�et to death
<br />'�` d) Coronary Artery Disease � Ye��
<br />18. PART IL OTHER SIQNIFICANT CONDITIONS-Cond(tlor� contrlbuUng to the death but not reaulUng In the umieriytng eauae given in PART 1. 19. WAS MEDICAL EXAANNER
<br />$eizure Disorder, Dapression, Hypothyroid, Hypertension oR CORONER CoNTACTED?
<br />�
<br />❑ ves Q ao
<br />W 0. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED4
<br />� (a w�e v�a�wni a�r�• � r�,�i ❑ Ho�uwae ❑ o.w��roa�ro. � trES � No
<br />W � P�epnaM at tlme ot death � Pas�n9er
<br />V � AcWtle�R � Pending InveatlBeBon
<br />� Q NM pregnant, but pregnant wRhln 42 days of death S �� �� ���� � Pedestrlan 21d. WERE AUTOPSY FlNDINGS AVAILABL
<br />a � Not preg�m�rt, bw pregnaM 49 aaye to t year beiore death � � � Other �Speciry) TO COMPLETB CAUSE OF DEATH7
<br />� � Unlmown fi pregnant withln the Peat Year ❑ YES ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PIACE OF INJURY•At home, farm, street, factary, offlee bullding, eonstruction site, etc. (Speetfy)
<br />E
<br />$
<br />� 22d. INJURY AT WORK4 22e. DESCRIBE HOW INJURY OCCURRED
<br />H
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (MO., Day, Yr.) 24b. TIME OF DEATH
<br />B March 27, 2012 S��
<br />��� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� � Z March 28, 2012 07:15 PM �<� •
<br />g i� d 28d, To fhe beat oi my Wowledge, death oecurted at the tlme, date and place $� � 24e. On the 6aeis ot e�minatlon entuor Imreatlgatlon, in my opinlon death oceurtetl at
<br />8 I sna due m tne muee(e) atatea. (s�e�mwre aml rwe) �� the tlme. dete and Place end due to the eause(s) sfated. (Signature and TfGe)
<br />'' ,� Kimberly A. Mfekels, MD ~ �g B
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH9 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 28b. WAS CONSENT GRANTED?
<br />� YES ❑ NO' ❑ PROBABLY � UNKNOWN ❑ YES � NO Not AppUcable H 28a Is NO ❑ YES ❑ NO
<br />2. 1 D F CER IFIER (P 1 S R ER P R A ORN ype or PrIM
<br />Kfmberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'8 SIONATURE �- 28b. DATE FlLED BY REGISTRAR (Mo, Day, Yr.)
<br />April 5, 2012
<br />
|