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<br />STATE OF NEBRASKA �
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND %��U�I�V.SERVICES, TT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE W1TH THE NEBRASKA L�P� MEI�I�" �,�IE�4TM AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VFT�IL l��(.''�L�S `�� ,° , b d, `
<br />1 ¢ �
<br />DATE OF ISSUANCE � � �y pf, .
<br />��/������+�°�, l ,,
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<br />07/10/2012 2 0 � 2 0 ,� 4 g 4 ST�w�� �oo�� � �
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<br />DEQ�I�'MEIV�.;��1�4;�T�INd :`� ',�
<br />LINCOLN, NEBRASKA HU Ad1F SERVICES ° .` � ���"
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV C .; �'� {� f t ���a' • ,� ' 42,02419
<br />�.cr���rwf+��vrur��n c„",.�,' r,� °�
<br />1. DECEDENTS-NAME (First, Middla, Last, Suftbc) 2. SEX �`, , '� 31pPnTE OF DEATH (Mo., Day, Yr.)
<br />Robert James Lambe Male `�'•Jul'y'4, 2042
<br />4. CITY AND STATE OR TERRffORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Laet Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MINS.
<br />Ulysses, Nebraska 90 February 9, 1922
<br />T. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />507 H PR ❑ tr�,aaer� OTHER � Nuratng Home/LTC � Hoeplee Facllity
<br />Bb. FACILITY-NAME (ff not I�UtuUon, give aVeet and number) � ER/Outpatle�R ❑ Decederrt's Home
<br />�
<br />DOA Other (SpeeHy)
<br />� Lakeview-A Golden Living Center ❑ ❑
<br />� 8c. CITY OR TOWN OF DEATH (Ineiude Zip Code) ed. COUNTY OF DEATH
<br />'c Grand Island 68801 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />LL ed. STREET AND NUMBER . APT. NO. 8t. ZIP CODE 9g. INSIDE CITY LIMITS
<br />�, 504 Kenned Place 68803 � res ❑ No
<br />� 70a. MARITAL STATUS AT TIME OF DEATH � Nlartled � Never Marrled 10b. NAME OF SPOUSE (Firat, Mlddle, Last, Suffix) IT wife, give rtmiden mame
<br />� ❑ nnarriea, but separated ❑ vndowea ❑ o�vorcea ❑ unicnown Nadine Alshouse
<br />m
<br />� 71. PATHER'S•NAME (Flrst, Mtddle, Last, Suffl�c) 12. MOTHER'S-NAME (Flrat, Mlddle, Malden Sumame)
<br />� James Lambe Clara Relnders
<br />°' 73. EVER IN U.S. ARMED FORCES7 Give dates oi aerviee If Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />� �res, No, or unic.) No Nadine Lambe Spouse
<br />,$ 15. MEfHOD OF DISPOSITION 78a. EMBALMERSIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� ❑ sunai ❑ oonaUOn Not Embalmed July 6, 2012
<br />� CremaUon ❑ Errtombmerrt 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Ramoval ❑ Other (Specify)
<br />Central Nebraska Crematlon Services Glbbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRES& (Street, CHy or Town, State) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE O DEATH ee Instructtons and exam les
<br />1B. PART I. FrtOer the chaln of eve��dlaeasea, NJuriea, or complicatlonadhat tllrecUy eaused the tleath. DO NOT e�rter tenninal everAS auch as cardiaa arrest, ; APPROXIMATE INTERVAL
<br />r�piraWry ertest, or veMricular fibrl0atlon wfthout ehowinp the eHOtopy. DO NOT ABBREVIATE. Frrter ony one cauae on e li�re. Add additlenal Mes If nersseary.
<br />IMMEDIATE CAUSE: ; o�et to death
<br />uere�ourecause� a) Dementla With Behavloral Disturbance ; Years
<br />diaease or contlkion resuitlrtg
<br />�' d � ' � DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />8equendally Iiat condklon& H b)
<br />a�ry. teading to the cauee flsted ',
<br />on tl�re a DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />�ru,a u��vnao cause �)
<br />(aieea� or InJury that inlUated '
<br />the eveMe reaultlng �n death) DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />� d)
<br />18. PART It. OTHER SIGNIFlCANT CONDITIONS-CorMlUorre contrlbuting to the death but not resultlng In the u�Mertying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />Atrial Flbrillatlon, CAD, GERD, Hypertension, Lumbar Spine Stenosis, Osteoporosis OR CORONER CONTACTED?
<br />� ❑ ves � No
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21e. WAS AN AUTOPSY PERFORMEDT
<br />� � Not pregnaM wMidn paet year � Natural � HoMdde � DrivedOperator �� � NO
<br />� � Pregnarrt et dme oi death � qccldeM � Pending Inveatigadon ❑��°��
<br />� Not pregna�rt, but prepneMwMhin Q2 daye of death g�dde Coutd not be determUred � PBdeaM°" 21d. WERE AUTOP9Y FINDINGS AVAILABLE
<br />� � Not prepnairt, but prepnairt 49 days ta 1 year before Eeath � � � p�� �gp��y� TO COMPLETE CAUBE OF DEATH?
<br />� � UNmown fl Preenant wkhln the paet year ❑ YES ❑ NO
<br />m
<br />E 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office butlding, co�truetlon stte, etc. (SpecHy)
<br />�
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />1�-
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET B NUMBER, APT.NO. CITYlfOWN 8TATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />b� � July 4, 2012 B�
<br />��� 23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH ��' �} 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />�' � Z Jul 5, 2012 06:00 PM E d a¢
<br />$� � 9d. To the beet oi my ImowledBe. death oeeurtetl et the tlme. tlate snd ptaee $��� 24e. On the basle oi exemineflon entllor ImeaUpaUon. ln my oPlNOn Aeath oeeurted at
<br />� - and dua to the cause(e) statetl. (Slgnature and Tkle) � � ure nnre date and place and due to the cause(s) afatetl. (SlBnature mM TIUe)
<br />~� Kimberiy A. Mickels, MD '" o 0
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED4 26b. WAS CONSENT GRANTED?
<br />� YES � NO ❑ PROBABLY � UNKNOWN ❑ YES � NO Not Appllcable H 28a ta NO ❑ YES ❑ NO
<br />2. TITLE D D F ERT IER P I , N P I R A (Type or Prlrrt
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �• � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 9, 2012
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