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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Charles Gordon Robbins 2. SEX ' Male 3. DATE OF DEATH (Mo., Day, Yr.) February 23, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Long Beach, California 5a. AGE • Last Birthday (Yrs.) 72 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 27, 1939 MOS. DAYS HOURS I MINS. 7. SOCIAL SECURITY NUMBER 505 -52 -3220 8a. PLACE OF DEATH HOSPITAL ❑ inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (if not Institution, give street and number) Wedgewood Care Center ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1703 West Charles 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 101). NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Edith V Riemschneider 11. FATHER'S -NAME (First, Middle, Last, Suffix) Gordon Robbins 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Adrienne (sham 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Edith V Robbins 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) February 29, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Shelton Cemetery Shelton Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART I. Enter the chain of events -- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Years respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Debility Unspecified - Progressive disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Cerebral Vascular Accident 18 Years any, leading to the cause listed line on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c ) (disease or Injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hypertension, Coronary Artery Disease, Diabetes 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending investigation 0 Suicide ❑ Could determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE S W i ix r e 2. 23a. DATE OF DEATH (Mo., Day, Yr.) February 23, 2012 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) February 28, 2012 23c. TIME OF DEATH I 12:40 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 g 0 3d. To the best of my knowledge, death occurred at the time, date and lace P B and due to the cause(s) stated. (Signature and Title) te W Kimberly A. Mickels, MD 24e. On the basis of examination and/or Investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES N NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, Kimberly A. Mickels, MD, 729 North Custer Avenue, HYSICTAN ASSISTANT, ONEWS PHYS`fCIAN OR COUNTY A'TORNEY) (Type or Print) Grand Island, Nebraska, 68803 1 28a REGISTRAR'S SIGNATURE °‘' 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 28, 2012 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 03/01/2012 2013 0 2119 STANLEY-S.. COOPER ASSI5.TANT STATE REEiISTI9IR DEP "1�,TENT OF HEALTH AND LINCOLN, NEBRASKA - HUM SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S'RVICFS CERTIFICATE OF DEATH 12 00663