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sTATE OF tvEB9�ASKA 201208963
<br /> WHEN THZS COPY CLIRRIES THE RAISED SEAL OF THE NEBR.4SKA DEPARTMENT OF HEALTH AIUD HUMAN SERVICES,IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WZTH THE NEBRASKA DEPARTMENT OF YEALTH AND
<br /> HUMAN SERVICES, VITAL RECQRDS OFFICE, WHICH IS THE LEGAL DEPOSITOR�Y FO{R VZTAL RECORDS_
<br /> OATE OF ISSUANCE ''o�.�+��+�� C J � Y _
<br /> 09/28/2012 STANLEY S. COOPER
<br /> ASSISTANT STATE REGZSTR,4R
<br /> DEPARTMENT OF HEALTH AND
<br /> LINCOLN NEBR.45KA HUMAN SERVICES
<br /> , STATE OF NEBRASKA-DEPARTMENT OF HEALTH�.AND HUMAN�.SERVICES 12 03551
<br /> CERTIFICATE OF DEATH
<br /> 1.DECEDENT'S-NAME (First, Middle, Last, S�x) . ,2.SIX 3.DATE OF DEATH(Mo.,Day,Vr_)
<br /> Robert John Tesmer Male September 23,2012
<br /> �4.CITY AN�STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH Sa.AGE-Last Biithday b.UNDER�YEAR. 5c.UNDER'1 DAY 6.�ATE OF BIRTH(Mo„Day,Yr.)
<br /> �rs-) MOS. DAYS � HOURS MINS.
<br /> Loup City,Nebraska 68 August 31, '1944
<br /> 7.SOCIAL SECURITY NUMBER 8a.PLACE OF DEATH '
<br /> 569-60-5937 HOSPITAL �Inpatient � OTHER �Nursing Home/LTC �Hospice Faciltty
<br /> Sb.FACILITY-NAME pf not Institution,give sVeet and number)
<br /> �EWOUYpatient �Decedent's Home
<br /> C
<br /> � Saint Francis Medical Center ❑�oa ❑Other(SpeGify)
<br /> U
<br /> � 8c.CITY OR TOWN OF DEATH pncluda Zip Code) 8d.GOUNTY OF DEATH �
<br /> o Grand island 68803 Hall
<br /> Q 9a_RESIDENCESTATE 9b.COUNTY 9c.CITY OR TOWN ,
<br /> w Nebraska Hall Grand Island
<br /> z
<br /> LL 9d.STREET AND NUMBER � e..APT.NO. 9f_ZIP CODE 9g_INSIDE GTY LIMITS
<br /> �, 30'1'i Brentwood PL 68801 � ves ❑ Ho
<br /> a �Oa.MARITAL STATUS AT TIME OF DEATH Married Never Married 90b.NAME OF SPOUSE First, Middle, �,Last, Suf£x lf wife, �
<br /> -a Q ❑ ( ) give maiden name
<br /> d
<br /> '= �Marrietl,6utseparated ❑w�a�ea ❑Divorced ❑unxnown Eileen Wingert �
<br /> d
<br /> ' � 91_FATHER'S-NAME (First, Midtlle, Last, SuffUc) 12.MOTHER'S�-NAME (First, Middle, Maiden Slimame)
<br /> �
<br /> � Leopoid Tesmer Flrence Dilfa
<br /> �' �3_EVER IN U:S.ARMED FORCEST Give dates of service if Yes. '14a_INFORMANT-NAME '�. �4b.RELATIONSHIP TO DECEDENT
<br /> �
<br /> $ �ves,No,o�u�k_�No Eifeen Tesmer Wife
<br /> � 15.METHOD OF DISPOSITION �6a_EMBAtMER-SIGNATURE �6b.LCENSE NO. 't6c.DATE(Mo�,Day,Yr.)
<br /> � ❑Burial ❑oonation Nicolas Douglas 1279 ' � September 25,2012
<br /> �Cremation ❑Errtombment q6d.CEMETERY,EREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> ❑Removal ❑04her(Specify) j �
<br /> Central Nebreska Cremation Services Gibbon Nebraska
<br /> �'17a.FUNERAL HOME NAME AND MAILING ADDRESS(Street,City orTowry Stiate) 17h_Zip Code
<br /> All Faiths Funeral Home,2929 S.Locust Street,Grand Island,Nebraska ' 68801
<br /> CAUSE OF DEATH See instructions and exam les
<br /> 98.PART 1.Enterthe chain of events-4iseases,injuries,or comp�cations-that tlirectly causetl the�tleaih.DO NOT enterterminal events sueh as Cartliat artes[, . : qpPROXIMATE INTERVAL
<br /> rrspiratory artest,orventricular{{brillation wifhout shovring the etiotogy.DO NOT ABBf2EVIATE Enter�only one cause on a lin�A�d adtlRional lines if nece_.s�ry_
<br /> IMMEDIATE CAUSE= ; onset to death
<br /> IMMEOIATE CAUSE(Final a)Cardiopulmonary Arrest . ; Immediate
<br /> a��se o.�oo�.,amo���ws�.,9 ��
<br /> in aeatn) DUE TO�,OR AS�A CONSEQUENCE OR ; onset to death
<br /> sey�enx�anyrs-�conertvons,tr b)Chronic Obstructive Pulmonary Disease,Severe �
<br /> a..y,�eaa�.,9 to tne.��se rseaa � �
<br /> n��ne a.
<br /> DUE TO,OR AS A CONSEQUENCE OF: ;� onset to death
<br /> e�,xe�tne uNoers�viH�cwuse �)Coronary Artery Disease �
<br /> (tlisease o[injury that initiatetl '
<br /> the.eveMsiesuiting.intleath) DUETO,ORASACONSEQUENCEOF: onsettodeath
<br /> LAST d)
<br /> 18.PART 1L OTHERSIGNIFICANT CONDITIONS-Conditions corrtriliuting to the death but not resulting in the untlerlying cause given in PART 1. '19.WAS MEDICAL IXAMWER
<br /> DiObBtes � OR CORONER CONTACTED?
<br /> �, � ❑YES �NO
<br /> W 20_IFFEMALE 21a.MANNEROFDEATH 296.IFTRANSPORTATIONINJURY2-Ic-WASANAUTOPSYPERFORMED?
<br /> � �Notpregnantwithinpastysa� �Natural �Homicitle �Driver/Operator, � YES � NO
<br /> U �PregnafKattime�o£tleath �Accitlent �PentlinglmeYigation ❑Passenger i . . .
<br /> s �Not pregnant,but pregnantwith�n 4�aays of Eeam su v��e Coula not be aeterminetl ❑P d�e triar. i 2'I�d_WERE AUTOPSY FINDIN65 AVAILABLE
<br /> � � TO COMPLETE CAUSE OF DEATH7
<br /> a �Not pregnank but.pregnant 43 days�to�'1 year be£ore death �Oth r(SpeciTy)�i
<br /> w �Unknownifpregnantwithinthepastyear ❑ �S � NO
<br /> N
<br /> � 22a.DATE OF INJURY(Mo.,Day,Yr.) 22b.TIME OF INJURY 22c.PLACE OF INJURY-At home,farm,street,factory,o�ce 6uild�ng,constn�ction site,etc.(Specify)
<br /> 0
<br /> U
<br /> n 22tl.INJURY AT WORK? 22e..DESCRIBE HOW INJURY OGGURRED i
<br /> 0
<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,Vr.) 24b.TIME OF DEATH
<br /> '��z 8e�te,^.:b�r 24,20'{2,� 0934 AM
<br /> m �Y 236_DATE SIGNED(Mo.,Day,Va) 23c.TIME OF DEATH - m�.�r 24c_PRONOUNCED DEAD(Mo.,Day,Yr:)-24d.TIME PRONOUNCED DEAD
<br /> o�Z _a<� Se tember 23,20'12 09:34 AM
<br /> '-' ¢� 3d.To Ne best of knowled p ace G w�� �
<br /> my ge,Eeath occumeA aYthe flme,tlate antl I 24e_O�n tM1e basis of examination and/or Inves[Igation,In�my opinfon tleath occurretl at
<br /> - a�a aue eo me m�se(s)sr eea.�sg�.,amre a.,a rrt�e� a�p the Eme,Oate anG place antl dve to the cause(s)sfated.(Signature and Titlej
<br /> " E �o o Sarah Carstensen,Hall Deputy County Attomey
<br /> 25.DID TOBACCO USE CONTRIBUTE TO THE DEATH7 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSI�ERED? 26b_WAS CONSENT GRANTED?
<br /> �YES ❑ NO ❑PROBABLY ❑ UNKNOWN ❑VES �NO NotApplicable if26a is Fl0 ❑YES ❑NO
<br /> 27_NAME,TITLE AN�ADDRESS OF CERTIFIER(Type or Print) � '� � �
<br /> Sarah Carsfensen,Hall Deputy County Attomey,231 S_Locust,P_O.Box 367,Grand Is[andi,Nebraska,68802
<br /> 28a_REGISTRAR'S SIGNATURE �_ 286.DATE FILED BY REGISTRAR(Mo_,Day,Yr.)
<br /> September 25,20�2
<br />
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