|
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 DEPARTMENT or HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL,RECORDS ,.
<br />1. DECEDENTS44AME (First,'': MMRe, '. LAN, `. Suffix)
<br />Thomas Nelson Fisher
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Missouri Valley, Iowa
<br />7. SOCIAL SECURITY NUMBER <:.
<br />506- 40-1980
<br />6b. FACIUTY-NAME (R not kntlmYtlon, give street and
<br />VA Medical Center -Grand Island
<br />(1c. CITY OR TOWN OF DEATH (ka itde21p.
<br />Grand Island 68803
<br />9a RESIDENCE STATE
<br />Nebraska
<br />Ed. STREET AND NUMBER
<br />1815 North Huston
<br />10e. MARITAL STATUS AT TIME OF DEATH MI Monied ❑ Hever MenM
<br />❑ Rattled, but separated 0 Widowed ❑ Divorced 0 LInknOwn
<br />11.FATHER'S4IAME (First, MNNIe, Lest, Susan) :.
<br />Russell W Fisher
<br />13. EVER IN U.S. ARMED FORCES? Give debts of service WYes. 144. INFORMANT -NAME
<br />(Yes, No, sr Unk.) Yes 06/06,1956 08/28/1959 Kindy Massing
<br />16. METHOD OF.DMPOSRION::: 16s. ER -SIGMA
<br />Moab 0ooaction
<br />❑turreted n ❑°"°" wtnt
<br />ORanovel ❑I
<br />17e. FUNERAL HOME NAME AND MAIUNO ADDRESS latest, City or. Town, SWe)
<br />Livingston - Sondermann Funeral Home, 601 N, Webb Road, Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />PS. PART I. MAW em jaMIL L • dleeaW"Idee. er eenala•sene. sat ewe* awes Se 4ra DO Pawnor meow warm nun as cross arreR
<br />mpwabry ravel, arapAAulrRiYMke without Mamas Me e66090.00 SOT A6MIEVN1E Inter aft sew tame en aUlw. Add ea.Med bee ltmmeeary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting'
<br />In death)
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, I
<br />arm leading to the cause listed b, .
<br />on line
<br />DUE TO, OR AS
<br />Entrthe UNDERLYING CAUSE c) C _ lc- CC,,.AtY
<br />(Mums or I nbsy that ed.:.. DU TO, :OR AS A: CONSEQUENCE OF:
<br />tea events moulting In death)
<br />LAST
<br />16. PART IL OTHER SIGNIFICANT CONDITIONS'CoMation• contributing to the death but not resulting in the underlying cause liven in PART .L
<br />24. IF F
<br />❑ Not preprint witiln past year
<br />Pregnant at time of death
<br />❑Not bagmen, big pregnrdwitidtn 42 days of deeb
<br />▪ Not Pregnant but MONO :43 days to 1 yew before dean
<br />❑ Un novm If pregnant within the past year
<br />22a DATE OF INJURY (No., Day, Yr,)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />2Z LOCATION OF INJURY = STREET & NUMBER, APT. NO.
<br />DATE OF ISSUANCE
<br />05/30/2013
<br />LINCOLN, NEBRASKA
<br />d)
<br />REGISTRAR'S SIGNATURE
<br />Lb. COUNTY ;.
<br />Hall
<br />22b. TIME OF INJURY
<br />m:
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />201305405
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Se. AGE-Last t Bir Birthday
<br />(Yre.)
<br />74
<br />ttl6.
<br />CEMETERY, :CREMATORY OR OTHER L OCATION
<br />Westlawn Cemetery
<br />ion NAME OF 8AOU8E IFist. VMdrs, WI.
<br />Linda Roggy
<br />21e. MANNER OF:DEATH
<br />Q IlonlcIde
<br />bad ❑ Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />22c. PLACE OF INJURY-At home, tern► skeet, factory, dfRa balking, conk lction sib, eta. (SplIy)
<br />t2TYrrOWN
<br />6b. UNDER 1 YEAR
<br />MOIL
<br />p.: PLACE OF DEATH
<br />MIMS: ❑ Imp darn
<br />❑ ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN :.:...
<br />Grand Island
<br />DAYS
<br />APT. NO.
<br />12. MOTHER'S44MME (FNat,
<br />Sophia Robak
<br />2. SEX
<br />Male
<br />CITY/TOWN
<br />Sc. UNDER .I DAY
<br />HOURS
<br />Ed. COUNTY QF DEATH
<br />Hall
<br />Suffix) If vAle, She maiden
<br />Grand Island
<br />21b. IF TRANSPORTATION
<br />❑ Dolvedoparator
<br />❑ Passenger
<br />❑ Fwabf•n
<br />❑ Other ISPecNy)
<br />24a. DATE. SIGNED (Mo., Day, Yr.)
<br />M)NS
<br />St. ZIP CODE :.'.
<br />68803
<br />Middle Malden Sunntlro)
<br />.PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />26 DID TOBACCO USE • • TO THE ORGAN OR TISSUE / DONATION BEEN CONSIDERED?
<br />\KYES :❑ No a PROBABLY' 0 :: ❑ YES pf NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Typo or Print) � '1...
<br />STANLEY S. COOPERS .1-
<br />ASSISTANT ,STATE REGISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES
<br />3. DATE OF
<br />May 18,2013
<br />S. DATE OF BIRTH loo.. Day. Yr.)
<br />July 19, 1938
<br />gmem ®: Nursing HOmATC 0 Hospice Fealty
<br />o Decedent'. Hama
<br />0 Oun41**,47 )
<br />Og. INSIDE CITY UNITS
<br />®r» ❑ Nd
<br />1411. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />tic. DATE (MO., Day. Yr.)
<br />May 28; 2013
<br />STATE
<br />Nebraska
<br />I
<br />176. Code
<br />68803
<br />APPROXIMATE INTERV
<br />onset to death
<br />a onset to dealt a.
<br />onset to deal
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YEE °! No
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO CO CAUSE OF DEATH?
<br />❑ YESNO
<br />STATE ZIP CODE
<br />24b. THE OF DEATH
<br />21d. THE PRONOUNCED DEAD
<br />240. On the heels of sxanlnstlon andtor Investigation. In my *pagan ARM occunad `.
<br />at the tim dote and place and due to the entomb) stated. (Signature and Tlle)
<br />Mb. WAS CONSENT GRANTED?
<br />Not Applicable 82M Is NO : ❑ . YES .
<br />26b.. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAY 1 8 2013
<br />m
<br />
|