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1. DECEDENTS -NAME (Fhst,. Middle,... Last, Suffix) r,y�.r.• �_
<br />Robert Clifton Chipps .>
<br />2. SEX •
<br />Male
<br />Sc. UNDER 1 DAY
<br />3. DATE OF DEATH(MO,Day,Yr.)
<br />May 28, 2013
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 25, 1921
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OR BIRTH
<br />Mason City, Nebraska
<br />Ea AGE•Laat BRIM.
<br />(Yrs.)
<br />91
<br />!b. UNDER t YEAR
<br />MOB..
<br />DAYS
<br />HOURS
<br />:: MINS.
<br />7. SOCIA). SECURITY NUMBER
<br />507 -38 -6483
<br />S.. PLACE OF DEATH
<br />N45P J Teug l Inpahtent onset ❑ Nursing HofWILTC 0HospleeFacility
<br />0 ER/Outpatient Q Decodentt Home
<br />at
<br />0 D0A Oth )
<br />Sb.:FACILITY• NAME (If not InatttutIon, give street and number)
<br />Veterans Affairs Medical Center
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code) Ed COUNTY OF DEATH
<br />Grand Island 68803 1 Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />Sb. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Pd. STREET AND NUMBER.
<br />1022 N. Howard Avenue
<br />9e. APT.. NO.
<br />91. ZIP CODE.
<br />68803
<br />5g. INSIDE CITY LIMITS
<br />® Y.:> ❑ No
<br />10e. MARITAL STATUS AT TAW* OF DEATH go Marled. 0 Haver Merited
<br />El "did' bet separated ❑ widowed : 0 Dhvorced ° Unknown
<br />tab. NAME OF SPOUSE (First, incite, Lest, Suffix) N vit*. glee maiden Pante.
<br />Katllr n Anna Seifert
<br />11..FATHEt'S -N (First, Middle, ' Sufx)
<br />Howard Chinos ''
<br />12. MOTHER'S-NAME (First, Middle, Malden Sumame)
<br />Ona Schaper
<br />13. EVER IN U.S. ARMED FORCES? Give dates of, Novice R Yes.
<br />(Y„, No, or Unit.) Yes 09/23/1942 - 10/18/1969
<br />14a. INFORMANT-NAME
<br />Kati n Anna Chipps
<br />14b, RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16. METHOD OF DISPOSITION
<br />Meade Donation
<br />❑c...www QEntoneweht
<br />Elawooral QOth.dawtpyl
<br />EMBALMER •• RE t
<br />t/
<br />18b. LICENSE NO.
<br />1.0 7
<br />14c. DATE (Mo., Day, Yr.)
<br />May 31, 2013
<br />lid. C , EMETERY CREMATORY OR OTHER I. TKXN CRYITOWN STATE
<br />•
<br />Fort McPherson National Cemetery Maxwell Nebraska
<br />y
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Street. City or Town, Slats)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Cod.
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />it Pratt Erdarthe pgagg o .dNwae,:hPM% Cr 011101aeons -lhat dhaay cowed De draw PO NOT wow tweed wants such aswdaw airmL i APPROXIMATE INTERVAL
<br />respiratory onset, Of vandodernbhkadoe wafted showing IM.adolnpy. DO NOT ASBREWATE.L4har only one cease on a lha. Add additional Una If naaraery.
<br />IMMEDIATE CAUSE: :. onset to death
<br />IMMEDIATE CAUSE (Final
<br />dlssasewcondltsn.....ng e) \kt, t •`.
<br />In d eath ► L. O.CC 1 .1RP *....s..,,,,,,,,,. © lit o:.,
<br />DUE TO, ORASA CONSEQUENCE Of: i onset to death
<br />sepu.ndagy got tconditions, ff �, `\:
<br />any. lading to ma calla. listed b) l e \ of . \ o. ' � - t"/At . �C 1 .\ . M'tO tk A C1 me 't") 1
<br />.
<br />on Linea DUE TO, OR AS A CONSEQUENCE OF: . i onset to death
<br />Enter the UNDERLYING CAUSE el 0. \ , n \ ` \� �t\(W i . .
<br />{
<br />\ Ag
<br />(discos or Injury : Shat in 1
<br />DUE TO, OR A ENCE OF: i. onset to death
<br />CC
<br />Sla.v.nbraulBnSindath).. -
<br />LAST
<br />d)
<br />.1 8. P l• IL OTHER SIGNIFICANT CONDIT ONS•Condltlone conbuting
<br />• Zn C) IN 5: 1 Ni t. \\ c- r ,:�
<br />e M IL VC I.
<br />20. IF F =
<br />°Not pregnant within past year
<br />❑Pr gnat at thus of death
<br />QNot pregnant, but pregnant wNldn 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 />tri to the death t not asulthm In S L a underlying cause given In PART
<br />o ` t� t\C Cl11 Ole , :..
<br />♦ a.. •
<br />as, bIS_1 11.
<br />1g. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ? i.NO
<br />1 21e. MANNER OF ' TH
<br />Natural ° Homicide
<br />Accident 0 Pending Investigation
<br />❑ Suicide ° Could not be.datennIned
<br />b. IF IRAN ,I • - TATION. I r' RY
<br />0 Driver/Operator
<br />0 Paesager
<br />❑ P.d.atdan
<br />0 Other (Specify)
<br />214. WAS AN AUTOPSY PERFORMED?
<br />° YES j4 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />: TO COMPLETE CAUSE OF DEATH?
<br />° YES
<br />22. DATE OF INJURY (Mo, Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />220. PLACE OF INJURY-At horn., famy street, factory, office building, construction alt., sm./SpeeNy)
<br />220. INJURY AT WORK?
<br />° YES 0 NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY= STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />k y
<br />a }
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Rt % ao t.._
<br />Y r
<br />rc c
<br />24.. DATE SIGNED. (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo.. Day, Y )
<br />24d. TIME. PRONOUNCED. DEAD
<br />m
<br />,
<br />23b. MTE irt NED (Yo., Day, Yr.)
<br />. D,
<br />t o i30
<br />236. TIME OF DEATH
<br />6 3O Cam
<br />24e. On Ma basis of axaminatIon and/or Invaetlgstlon, in my opinion death occurred
<br />at the Sin., data and place and due to the cause(s) stated. (Signature end Tido)
<br />■ � d0
<br />23d T of y knowd • • , dat ccuffed at tin time, date and place IN =
<br />. . th r use( ad. ( ,) /�,/ G �1 a g z
<br />F
<br />26. DID TO USE CON BUJ • THE DEATH? ,: „� .aer
<br />❑ YES NO 011I BABLY 0 UNKNOWN
<br />1 ORGAN OR = ', • N BEEN CONSIDERED?
<br />❑ YES 0 NO
<br />28b. WAS CONSENT GRANTED? �r
<br />Not Applicable H 28.1. NO ❑YES 6� NO
<br />27. NAME, D ADDRESS OF CERTIFIER (Type or Pu nt)
<br />c la Ziliali . ekocn` iet t9R
<br />s V\Qigt , Sg(\\ ` cW'� rt MO. Y�M� 4th `R.$corm l.,ell C.t�
<br />tEG
<br />28.. REGISTRAR'S SIGNATURE
<br />N•
<br />28b. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />JUN .3 2013
<br />re
<br />LU
<br />U.
<br />DATE OF ISSUANCE
<br />06/05/2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201600874
<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 QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS..
<br />STANLEY S COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />HUMAN'SERVICES, .
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />rCDTI)^1rATrw d"h r1CATR1
<br />
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