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STATE OF NEBRASKA tom .. dekCibrafirraffil 9r faxiiala 1■,• r LL re E 0 1d WHEN'! THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 5/23/2016 LINCOLN, NEBRASKA 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Edwin Henry Baasch 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cairo, Nebraska 7. SOCIAL. SECURITY NUMBER 508 -30 -7860 6b: FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE STATE Nebraska 9d. STREETAND NUMBER 405 Rosewood Circle 10a. MARITAL STATUS AT, TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Alfred Baasch ,EVER IN U.S ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, or Unk.) Yes ;06/29/1944- 06/04/1946 Bernice A Baasch 5. METHOD OF DISPOSITION ® Burial Q Donation ❑ Cremation ❑ Entombment Removal 0 Other(Specify) 7a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)!! Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska a, PART t. Enter the chain of events - -diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respirarory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a lint. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) lschemic Bowel disease or condition resulting kc death) Sequentially list cOndItions, rf any, leading to 010 cause listed on line a. Enter the UNDERLYING CAUSE (disease dr ttyury that initiated the events resulting death) LAST. 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Esophageal Neuroeridocrine Tumor 20. IF : FEMALE: ❑ Not pregnant Within past year ❑ Pregnant at time of death ❑ ,Not pregnant,. but pregnant within 42 days of death Nat pregnant OM pregnant43 days to 1 year before death Unknown itpiegnaMwithin the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2d, INJURY.AT'WORK? ❑ YES ❑ NO 22f, LOCATION OF INJURY - STREET & NUMBER, APT.NO. 2 DUE TO, OR AS A CONSEQUENCE OF: b) Atherosclerosis DUE TO, OR AS A CONSEQUENCE OF: c) 22e. DESCRIBE HOW INJURY OCCURRED a. DATE OF DEATH (Mo., Day, Yr.) May 13, 2016 23b. DATE SIGIMI D (Mo., Day, Yr.) i..ic. TIME OF DEATH cc u z May 13, 2016 02:00 AM a 0 3d. To the best of my knowledge, death occurred at the time, date and place a G and due to the cause(s) stated. (Signature and Title) Travis S. Hageman, MD REGIS TRAR'S SIGNATURE 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Christopher J. Loecker 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery DUE TO, OR AS A CONSEQUENCE OF: d) STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 5a. AGE . Last Birthday 5b. UNDER 1 YEAR (Yrs,) MOS, DAYS 91 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Bernice Amanda Schultz 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CAUSE OF DEATH (See instructions and examples) CITY/TOWN DOA 9c. CITY OR TOWN Grand Island'' 9e. APT. NO. 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS OR IN YES ❑ NO • ❑ PROBABLY ❑ UNKNOWN ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 J6 v�"K - 2. SEX Male 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 12. MOTHER'S -NAME (First, Middle, Ingrid Andreasen OR TISSUE DONATION fia NO 1 164. LICENSE NO. 1421 8 E CITY / TOWN Grand Island STATE 24a. DATE SIGNED (Mo., Day, Yr.) CONSIDERED? AT STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) HOUNCED DEED (Mo., Day, Yr.) 6. DATE OF BIRTH (Mo.„ Day, Y February 17, 1925 Maiden Surname) 16c. DATE (Mo., Day, Yr.} May 16, 2016 1 17b Zip Code 68801 onset to death 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 281,. DATE FILED BY REGISTRA May 17, 2016 3. DATE OF DEATH (Mo., Day, Yr.) May 13, 2016 ❑ Hospice Facility 9g. INSIDE CITY LIMITS I; Ea YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse STATE Nebraska APPRO)UMATE INT INTERVAL onset to death One Day 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGSAVAILABL TO COMPLETE CAUSE OF DEATH ?. ❑ YES ❑ NO 411. TIME PRONOUNCED DEAD MP.,Day,Yr.)