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DATE OF ISSUANCE
<br />LINCOLN, NEBRASKA
<br />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 .D eARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V.1TAL OECOAD$.
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<br />09/10/2014 201604301 y' 7:64L S. coos.. •
<br />ASSISTANT STATE REGIST
<br />, I-DEPARTMENT QF 4JEALTI1;fi
<br />G "`H&IMA/V SS,8V,!CE$ , • 1.'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SBRY(ICES
<br />CERTIFICATE OF DEATH `,,, °•: � ,
<br />14 04488
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Robert Richard Yates
<br />2: SE1t,1' r ' • . " �) !
<br />Male' ,'r i s,
<br />31)jATEa bE!(7H (Mo., Day, Yr.)
<br />, Se}tereer 6, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />79
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 D,d
<br />6 I wain* BIRTH,(Mo., Day, Yr.)
<br />August 7, 1935
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINE •
<br />7. SOCIAL SECURITY NUMBER
<br />507 -38 -7383
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Regional West Medical Center
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />j
<br />I8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Scottsbluff 69361
<br />8d. COUNTY OF DEATH
<br />Scotts Bluff
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Scotts Bluff
<br />9c. CITY OR TOWN
<br />Gering
<br />9d. STREET AND NUMBER
<br />1910 Q Street
<br />9e. APT. NO.
<br />8f. ZIP CODE
<br />I 69341
<br />9g. INSIDE CITY LIMITS
<br />IA YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Metta M DeKay
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ivan Yates
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Grace Ann Hayek
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 05/04/1958- 08/06/1962
<br />14a. INFORMANT -NAME
<br />Randy Yates
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />September 8, 2014
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Dugan- Kramer Crematory Scottsbluff Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Gering Memorial Chapel, 1755 11th Street, Gering, Nebraska
<br />17b. Zip Code
<br />69341
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART 1. Enter the chain of events - -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />10 Days
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Acute Chronic obstructive Pulmonary disease Exacerbation
<br />disease or condition resulting
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />Sequentially list conditions, H b) I
<br />any, leading to me cause listed t
<br />I
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />Enter the UNDERLYING CAUSE c) I
<br />(disease or Injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LAST d) I
<br />I
<br />I
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Transverse Myelitis, Right Heart Failure
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 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 />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 2:1 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />3 w
<br />re r
<br />w z
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 6, 2014
<br />Z
<br />n 5 id
<br />i E k ,.
<br />o. 5 Z
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />S eptember 8, 2014
<br />23c. TIME OF DEATH
<br />10:43 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />U 0 3 d. To the best of my knowledge, death occurred at the time, date and place
<br />o c and due to the cause(s) stated. (Signature and Title)
<br />f Mithun Sreekantan, MD
<br />s w z 0
<br />2 G O
<br />` fi s
<br />24e On the basis of examination and /or Investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Mithun Sreekantan, MD, 3911 Avenue B, Suite
<br />2100, Scottsbluff, Nebraska, 69361
<br />1 28a. REGISTRAR'S SIGNATURE _
<br />Al -•O -
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 9, 2014
<br />DATE OF ISSUANCE
<br />LINCOLN, NEBRASKA
<br />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 .D eARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V.1TAL OECOAD$.
<br />/
<br />ti t
<br />fi� t,,
<br />09/10/2014 201604301 y' 7:64L S. coos.. •
<br />ASSISTANT STATE REGIST
<br />, I-DEPARTMENT QF 4JEALTI1;fi
<br />G "`H&IMA/V SS,8V,!CE$ , • 1.'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SBRY(ICES
<br />CERTIFICATE OF DEATH `,,, °•: � ,
<br />14 04488
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