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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AI�ID hlU�?�V S�RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS(�f'DEP�TME��I YJ� HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR �l�ITAL:'RE�p.l2pS.e .' ;, t r
<br />.- . ' f� .
<br />DATE OF ISSUANCE � �` �'� (�''p
<br />� - i L� .* � ° ' y.,
<br />10/03/2012 � 0 f 2 O g 3 9 3 �-,�►«y S. �ooP�R �- ���
<br />lk5.51'STAl1(�'Sa'AT�R6f,ISTRAR �>"
<br />��'PARTM�T�C�F�i�ALTM AJVD' ;'�.
<br />LINCOLN, NEBRASKA I�UI►�4N. SERVICES - �
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SE��/ICES •.'� r � � Z`` '� .�"� •�''" 12 03618
<br />ACI7T�r�A �TC Ar !\C �TIJ A � :� P. � ,� .� q .'
<br />VGRI Ir�VM1 G Vr YGMI Il - k � p �. � °
<br />1. DECEDENTS-NAME (Fl�at, Mlddle, Last, Suftbt) 2. SIX � •� !, 3. OFDE/kTH (Mo., Day, Yr.)
<br />Jacob Joseph Bauer Male �` � �-$eptember 30, 2012
<br />4. CITY AND 9TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTN Sa. AGE - Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTM (Mo., Day, Yr.)
<br />0'►8•) MOS. DAYS HOURS IVONS. �
<br />Gothenburg, Nebraska 60 October 25, �1951
<br />7. SOCULL SECURITY NUMBER Ba. pLACE OF DEATH
<br />508 HOSPRAL � InpatleM OTHE ❑ Nursing HomeILTC � Hospice Facllity
<br />Bb. FACIU'fY�NAME (it not InsUtutton, give street aiM number} �y
<br />� ❑ OutpatlerR ❑ DeeedeM's Home
<br />� Saint Francfs Medical Center ❑ oon ❑ Other(Specffy)
<br />� ec. CITY OR TOWN OF DEATH prrclude Zip Code) Sd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 9b. COUNTY 8C. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER . APT. NO. ef. ZIP CODE 9g. INSIDE CITY UIWTS
<br />�, 325 Wainwright St 68801 � v�s ❑ No
<br />a 10a. MARITAL STATUS AT TIME OF DEATH � AAarrled � Never Marrled 10b. NAME OF SPOUSE (F(rst, Middle, Last, Suft6c) If wHe, gfve maiden mame
<br />�
<br />� ❑ nearr�ed but separated ❑ v�naowed ❑ o�vorcea ❑ unknown PaMcia Rhinehart
<br />m
<br />11. FATHER'S-NAME (Firsf, Mlddle, Last, Suftix) 72. MOTHER'S-NAME (First, Middle, Maiden Surt�me)
<br />� Jac�b Owen Bauer Phyllis Svoboda
<br />°' 13. EVER IN U.S. ARMED FORCES? Gtve dat� of aervlee H Yas. 14a, iNFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />g res,No,orUnk.)Yes 02/10/1971-01/31/1973 Patricia Bauer Spouse
<br />,� 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNpTURE 96b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ Burlal ❑ DorwUon
<br />Not Embalmed October 1, 2012
<br />� CremaUon � Fr�tombment �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Speci(y) �ntrai Nebraska Cremation Services Gibbon Nebraska
<br />77a. FUNERAL HOME NAME AND MAILINO ADDRESS (Street, City or Town, SYate) 17b. Zip Coda
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See nstructions an exam les
<br />18. PART I. EMer Ure ehaln of eve� dlseases, InJurlee, or complieadons-tAat dlrectiy cauaetl the deatlu DO NOT e�er terminal eveMe euch ae �srdlae arreat, ; qPPROXIMATE INTERVAL
<br />respiraWry artest; wvaMrlcular flbdilatlon rrithout showing Ne eUol�y. DO NOT ABBREVIATE Fartaz onry one cause on a Ma Add admtlonal Ilnes H neceawry.
<br />IMMEDWTE CAUSE: ; onset to death
<br />ieabeow� cause t� a) Sepsis From Ischemic Bowel 6 7.5 Hrs
<br />alsease or condkion reautting
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s�,��ny��e��amo�,ir b)gowel Perforatlon, Chronic : 2-3 Weeks
<br />am�. team�B ro we ca�se usma
<br />on Ii�re a DUE TO, OR f64 A CONSEQUENCE OF: : o�et to death
<br />�ru,.uNO�nNOCause �) �el Infectlon With Vancomycin Resistant Entercoccus And Candida : 2-3 Weeks
<br />(disease or InJury that InidaOed
<br />� �"B �" �'� DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />d) Ventral Hemla And Repair : 1 Month
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-CorMlUons co�ibutlng to the death but not resulUng in the urMertying puae given In PART I. 19. WAS MEDICAL EXANONER
<br />ORCORONERCONTACTED?
<br />� � YES ❑ NO
<br />W . IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJU 21c. WAS AN AUTOPSY PERFORMED4
<br />LL
<br />� � Not P�Bnenf wtthin P� Y� � Natural � HoM�ide � DdvedOperator
<br />� � Pre9naMattlmeo►death� �ACddeM �Pendln9lmeaUBedcn ❑P��9a� ❑ YES � NO
<br />� Not prepnant, WR preg�nt wtthln 42 daye of death � Pedeatrian 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� Q Not prepnairt, but pragnant 49 days M 7 year betore death ❑ SWdde � CoWd not be determined ❑ � r (s�i�) TO COMPLETE CAUSE OF DEATH?
<br />� ❑ Un�mown ti pre¢nant withln the P� Y�+ ❑ YES ❑ NO
<br />E 22a. DATE OF WJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, atreet, tactory, offlce bullding, correWction sRe, etc. (SpecHy)
<br />$
<br />� 22 . INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET 8 NUNBER, APT.NO. CITY/TOWN STATE ZfP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� ffi September 30, 2012 ,� � �
<br />� � 23b. DATE SIGNED (Mo„ Day, Yr.) 23c. TIME OF DEATH ��� Y 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DE4D
<br />$ � o October 1, 2012 01:15 AM g d<�
<br />� To the best M my ImowledBe. deafh oaurred at the firtre. date end Place $� �
<br />� and due to the causa(e) elated. (3lgnature eiM Tklel � 24e. On the basis a(e�taMnation and/or ImeatlBatloM M mY opinlon tleath occuned at
<br />e $ the dme� date aiM Plaee emd due to the ca�sele) statetl. (SlgnaW�e and TMie)
<br />0 0
<br />'" � Zac hary W. Meyer, M D ~ g s
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATHT 28a. HAS OROAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES � NO � PROBABLY ❑ UNIdJOWN ❑ YES � NO Not Applleable Ii 28a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND F ERTIFlE (Type or ►i
<br />Zachary W. Meyer, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �` . 28b. DATE FlLED BY REGi3TRAR (Mo, Day, Yr.)
<br />October 1, 2012
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