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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DkPARTMENT.eF HEALTH AND
<br />HUMAN S E R V I C E S , V I T A L RECORDS O F F I C E , W H I C H I S T H E LEGAL DEPOSITORY F O R VITAE REGOgDS. , 1 i
<br />DATE OF ISSUANCE
<br />10/11/2012
<br />CERTIFICATE OF DEATH
<br />CC�� c� q ((�� A n ,) , ,.
<br />Kr Q 2 .I. 1 V i AS NT S A REGIS7T R • e,
<br />DEPA THE O 'J-i L7 1 ANO :, '
<br />LINCOLN, NEBRASKA HUj SERY CE°S , ✓'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE. . A c- > r 12 03513
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Bernard Hughes Kisner
<br />2. SEX s
<br />Male ? 4
<br />3. DATE OF �,/, Yr.
<br />•' I$eptem r ,?
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Brownsville, Illinois
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />94
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF.BIRTH1Mo., Day, Yr.)
<br />January 12, 1918
<br />MOS.
<br />I
<br />DAYS
<br />HOURS
<br />MANS.
<br />7. SOCIAL SECURITY NUMBER
<br />337 -12 -3971
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />St Francis Skilled Care Medical Ctr
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ Eft/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other ( Sp•cify)
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2516 Apache Rd
<br />e. APT. NO.
<br />r
<br />9f. ZIP CODE
<br />I 68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Jo Ann Wehrle
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Talmage E Kisner
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Jessie Lucinda Hughes
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 04/18/1942 - 04/05/1952
<br />14a. INFORMANT -NAME
<br />Jo Ann Kisner
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />II Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER-SIGNATURE
<br />Kevin Wood
<br />16b. LICENSE NO.
<br />1325
<br />16c. DATE (Mo., Day, Yr.)
<br />September 25, 2012
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />17b. Zip Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the ghain of events- -diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Years
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Congestive Heart Failure
<br />disease or condition resulting
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, if b) Coronary Artery Disease Years
<br />any, leading to the cause listed
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c) Hypertension
<br />(disease or injury that initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Atrial Fibrillation, Chronic Kidney Disease, Hypothyroidism, Anemia
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ID NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending investigation
<br />❑ Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />I22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />b' W
<br />z
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 21, 2012
<br />3'
<br />< >
<br />8Cig
<br />2 1 L
<br />~ g s
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 21, 2012
<br />23c. TIME OF DEATH
<br />I 04:50 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />3d. To the beat of my knowledge, death occurred at the time, date and place
<br />2 and due to the cause(s) stated. (Signature and Title)
<br />2
<br />Jay C. Anderson, MD
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the time, date and place and due to the causes) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR
<br />❑ YES
<br />ISSUE DONATION BEEN CONSIDERED?
<br />El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue,
<br />Grand Island, N�- • . 8803
<br />128a. REGISTRAR'S SIGNATURE /} A • /�
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />September 24, 2012
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DkPARTMENT.eF HEALTH AND
<br />HUMAN S E R V I C E S , V I T A L RECORDS O F F I C E , W H I C H I S T H E LEGAL DEPOSITORY F O R VITAE REGOgDS. , 1 i
<br />DATE OF ISSUANCE
<br />10/11/2012
<br />CERTIFICATE OF DEATH
<br />CC�� c� q ((�� A n ,) , ,.
<br />Kr Q 2 .I. 1 V i AS NT S A REGIS7T R • e,
<br />DEPA THE O 'J-i L7 1 ANO :, '
<br />LINCOLN, NEBRASKA HUj SERY CE°S , ✓'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE. . A c- > r 12 03513
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