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To be completed by: CERTIFIER 1 1 To be completed /verified by: FUNERAL DIRECTOR 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Robert Lee Rohweder 2. SEX ' ''' `' Male .3. DATE OF DEATH (Mo., Day, Yr.) September 24, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday 6b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 5, 1930 (Yrs.) 85 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -40 -2356 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center 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 4011 Sacramento Circle 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS Q YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Arlene Ann Reher 11. FATHER'S -NAME (First, Middle, Last, Suffix) George Rohweder 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Ella Meyer 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 03/12/1951- 12/12/1952 14a. INFORMANT -NAME Arlene Ann Rohweder 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION El Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER•SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 16c. DATE (Mo., Day, Yr.) September 29, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events - •diseases, injuries, or complications4hat 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) Alzheimers Dementia disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b) 1 any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated ! the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST 1 d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Anorexia, Malnutrition, Nonhealing Foot Ulcers 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 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 ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE Z w 1 1- • E. ri z '23a. DATE OF DEATH (Mo., Day, Yr.) September 24, 2015 a c t) � 1 i I o a. .4 a c ' ix z . 2 o O � ~ . s 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 23b. DATE SIGNED (Mo., Day, Yr.) September 28, 2015 I 23c. TIME OF DEATH 08:50 AM o a O 3d. To the best of my knowledge, death occurred at the time, dalte and place and due to the cause(s) stated. J o c 0 O stated (S ignature and Title) Michael A. Donner, MD 24e. On the basis of examination and/or investig tion, in my opinion death occurred at the time, date and place and due to the cau e(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE A - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 29, 2015 STATE OF NEBRASKA 201507314 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 NEBRASIt94D PARIN NT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQ3 .RH 'OR DATE OF ISSUANCE 10/02/2015 STANLEY S CQOPER SSJST4 TATE REGx R DEPAR IT.O EALT2I' LINCOLN, NEBRASKA 1`)UNl STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN OR1ftCD$ CERTIFICATE OF DEATH 15 05611