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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH`ANDHt/MAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,DaPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL.RECORDS.
<br />STANLEY S. COOPER
<br />;A SISTANT:STATE REGISTRAR
<br />DEPARTMENT OF HEALTJ'I'AND
<br />HUMAN SERVICES
<br />DATE OF ISSUANCE
<br />05/31/2013
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First,
<br />Robert
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN
<br />10a
<br />Middle,
<br />Philadelphia, Pennsylvania
<br />7. SOCIAL: SECURITY NUMBER
<br />160 -40 -3251
<br />ga. RESIDENCE -STATE
<br />Nebraska
<br />Ed. STREET AND NUMBER I.
<br />10910 S. 18th Street
<br />it. FATHER'S-NAME (First, >; ::: Middle,
<br />William Whearty
<br />Sequentany Net conditions,
<br />N an leading to Si. cause
<br />gated en line
<br />UAIERRLWNG
<br />CADRE (dress ar fluty that
<br />bigoted the wane naming
<br />In death) LAST I.
<br />20. IF FEMALE:
<br />17 Not prepnaht within past year
<br />Pregnant at the of deatth
<br />U NO pregnant. bun pregnantOlen 42 days of death
<br />O Not prepmnt, but pai sBeadays tot year Delors dWh
<br />U Unknown II pregnant within the past year
<br />(b)
<br />(c)
<br />22a DATE OF INJURY (Mo ::Day, Yr.) :.
<br />22d. INJURY AT WORIt7
<br />❑ YES NO
<br />NO
<br />234. DATE OF DEATH (Mo., Day, Yr.)
<br />22 2t) S
<br />23b. DATE , N (Mo, Yr.)
<br />51'1 213
<br />23d. To Ste best of
<br />and due to I
<br />25. DID SACCO USE
<br />1YE O NO :
<br />REGISTRAR'S SIGNATURE
<br />PROBABLY
<br />E TO THE DEATH?
<br />27. NAME, TITLE AND
<br />201405669
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN
<br />CERTIFICATE OF DEATH
<br />Peter
<br />COUNTRY OF BIRTH >;
<br />. FACIUTY NAME (d not Institution, give street and number)
<br />10910 S. 18th Street
<br />Ac. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Bellevue
<br />AN COUNTY
<br />MARITAL STATUS AT TIME OF DEATH: Marred U Neer Married
<br />Maned, but separated O Widowed O Divorced 0 Unknown
<br />13. EVER IN U.& ARMED FORCES? Glvedotes of samba yes.
<br />(we,rio or WO Yes 8/23/724/31/98
<br />15. METHOD OF DISPOSITION 100. EMBALMER -SI
<br />Rune) O Denison
<br />O Cremation O Entombment
<br />O Removal O Other (speaty)
<br />Bellevue Cemetery !'
<br />lie. FUNERAL HOME NAME AND MAJUNG ADDRESS (Street, CBYor Tem. Sfale)
<br />01111A. Gen . . r Moro. ' 1010 N. 72 S
<br />MEDIATE CAUSE (Rini (a) WN
<br />d aaoreanadonresulthtg
<br />B death)
<br />DUETO, OR AS A CONSEQUENCE
<br />DUE TO. OR AS A CONSEQUENCE OR
<br />GUS OR AS A CONSEQUENCE OF:
<br />22b. TIME :OF INJURY
<br />m
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. <.
<br />O UNKNOWN
<br />or Print)
<br />230. TIME Of DEATH
<br />dean' occurred at the tie, data end place
<br />a) stated. (Signatem and Ude) ♦ '
<br />STATE OF NEBRASKA
<br />Sarpy
<br />14i.: INFORMANTNNNE .
<br />229
<br />Whearry I'
<br />5th AGE-Laid Birthday SN UNDER I YEAR
<br />CITY/Town
<br />nrs) 64
<br />Ba PLACE OF DEATH
<br />HQSf hLa U Inpatient
<br />ICE. NAME OF SPOUSE;. (First, MIdd4,:Last Suffix) 8 win give maiden name.
<br />J oanne E. Holliday
<br />Sully)
<br />ied CEME7 ,, OREI 1' OR OTHER LOCATION
<br />Omaha NE
<br />18. PART I. Enter the , Intone, orcompe cartons- thstdirectly awed She death. DO NOT enter termInal .0001* uGb as ca,dlac snail,
<br />respiratory west, or ventricular ebdesttonwithout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a ens. Add additional Ines neenrry
<br />IMMEDIATE CAUSE:
<br />Cft. c ER
<br />18. PART IL OTHER SIGNIFICANT CONDIT ONS•Condeons:anWmSrp to the death but nol mean ng In ardarning cause g van in PART I.
<br />MA3INER OF DEATH
<br />li'llestural O Homicide
<br />❑ AacIdentU Pandang InvadgNbn
<br />O Suicide O Could not be deterMnsd
<br />PLACE OF INJURY -IU home, farm, street, factory, oleo building, construction tn.,ete. (Speary)
<br />Bc. CITY ORTOWN
<br />Bel evue
<br />Be. APT. NO . a .aP CODE
<br />12. MOTHER'S-NAME (First,
<br />Marie A. Navin
<br />panne E. Whearty
<br />68123
<br />MOS,
<br />DAYS
<br />U ERlOsiatlnd
<br />a ow.
<br />AN LICENSE NO.
<br />2. SEX
<br />to UNDER
<br />HOURS
<br />Male
<br />Rd COUNTY OF DEATH
<br />f.
<br />Bellevue, Nebraska
<br />21b. IF TRANSPORTATION INJURY
<br />0 Drivar,Oparamr
<br />0 Passenger
<br />O Pedeatrlan
<br />a Other (Specify)
<br />RI DATE SIGNED (Mm.. :Day, Yr,)
<br />2Ba. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES
<br />ERVICES
<br />1 DAY
<br />MINS.
<br />MEG: O Nursing HOmeI.TC
<br />01 Decedent's Home
<br />'1
<br />O ow (SpeeBy)
<br />Sarpy
<br />68123
<br />13
<br />I onset a dee*
<br />onset to death
<br />I onset to
<br />24b. TIME OF DEMI
<br />238
<br />9.
<br />DATE OF DEATH (Mo., Day,Yr.) :.
<br />April 28,2013
<br />B.
<br />DATE OF BIRTH (Me, Dry, Yr.)
<br />January 15,1949
<br />I onset to death
<br />61
<br />O Hospice FeoaMY
<br />8g. INSIDE CITY UMITS
<br />YES ONO
<br />t en. DATE (Mo., Day. Yr. ) e :
<br />May 4, 2013
<br />death
<br />Maiden Surname)
<br />lab. RELATIONSHIP TO DECEDENT
<br />Wife
<br />STATE
<br />lb. Zip Coda
<br />68 114
<br />APPROXIMATE INTERVAL
<br />ie. WAS MEDICAL EXAMINER ".
<br />OR CORONER 90NTACTED7 '
<br />O YES
<br />210. WAS AN AUTOPSY PERFORMED?
<br />O YES
<br />2id.WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />O YES ONO
<br />STATE - - _ ZIP CODE
<br />24c. PRONOUNCED DEAD (Ma, Day, Yr.) MOUE DEAD
<br />4e. On tile basis of examination and/or:investigation, I. my opinion death occurred at
<br />the tine, data and place and due to the cause(s) stated. (Signature and Title )
<br />24b. WAS CONSENT GRANTED?
<br />Not Applicable 11211 A no O YES O
<br />286. DATE FILED BY REGI' TAR (Mo.. Day: Yr)
<br />MAY 2 0 2013
<br />X 0
<br />HHS -61 Rev. 412 (55061
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