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STATE OF NEBRASKA t r . � �3 0. F 0 W U E 0 O 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 6/30/2016 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Rodney Eugene Fisher CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Greele , Nebraska 7. SOCIAL SECURITY NUMBER 507 -56 -0463 b. FACILITY -NAME (If nottnstitution, give street and number) Wedgewood Care Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 . RESIDENCE -STATE Nebraska 9d. STREET ANA NUM 4064 Stauss Rd iR 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married Married, but separated ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, George Fisher 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 5. METHOD OF DISPOSITION ❑ Burial ;❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) IMMEDIATE CAUSE (Final disease or condition resulting in death) SegUeittlahy list Conditions, if any, reading to the Cause fisted on line a. Einar the UND'EFILY,NG CAUSE . or injury that initiated the events resulting In death) LAST 20.1F�FEMALE; ❑ Not ptegnant?Aithin past year 0 Pregnant at time of death. ❑ Not pregnant, but pregnant within 42 days of death Q Not pregnant; but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY '(Mo., Day, Yr.) 22d. INJURY AT WORK? YES 0 NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 23a. DATE Of DEATH (Mo., Day, Yr.) June18,2116 DATE SIGNED (Mo., Day, Yr.) June 20, 2016 28a.::REGISTRAR'S SIGNATURE 201604331 STATE OF NEBRASKA - DEPARTMENT OF HEALTH'AND HUMAN SERVICES CERTIFICATE O F DEATH COUNTY Hall Middle, Last, Suffix) 16a. EMBALMER - SIGNATURE Not Embalmed 5a. AGE - Last Birthday r 515. UNDER 1 YEAR (Y •) MOS. DAYS 72 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient 14a. INFORMANT-NAME Jacqueline Dockhorn ERlQutpatient ❑ DOA c. CITY OR TOWN Grand Island 10b. NAME OF SPOUSE (First, Middle, Last, Gloria Goering 1 12. MOTHER'S -NAME (First, Middle, Bertha McMahan 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska`" , PARt L Enter Pre hain ofevents diseases, injuries, or complications -that directly caused the death. DD NOT enter terminal events such as cardiac arrest, y arts al, at ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line;, Add additional lines if necessary. IMMEDIATE CAUSE: a) Multiorgan Failure DUE TO, OR AS A CONSEQUENCE OF: b)Gastrointestinal Bleed DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED CAUSE OF DEATH (See instructions and examples) 23c. TIME OF DEATH 02:30 AM 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY-At home, f CITY/TOWN 26a. HAS ORGAN OR Ti ❑ YES a 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) t- c ! 1 ij- ouwias H ibek, MD 25. DID TOSACC. O USE CONTRIBUTE TO THE DEATH? YES NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Douglas Herbek, MD, 2444 W. Faidley Avenue Grand Island, Nebraska, 68803 SSUE DONATION NO STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e, APT. NO. 2. SEX Male l 16b. LICENSE NO. 21b. IF TRANSPORTATION 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 5c. UNDER 1 DAY HOURS STATE 24a. DATE SIGNED (Mo., Day, Yr.) MINS. OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 INJURY 4c. PRONOUNCED DEAD (Mo., Day, Yr. Ca t � r 1 16 03613 3. DATE OF DEATH (Mo., Day, Yr.) June 18, 2016 6. DATE OF BIRTH (Mo., Day, Yr.. A4 ril 22 1944 Suffix) If wife, give maiden name Maiden Surname) 28b. DATE FILED BY REGISTRAR (M June 27, 2016 ❑ Hospice Facility 24b. TIME OF DEATH E a (n w 24e. On the basis of examination and /or investiga ion, in my opinion death occurred g the time, date and place and due to the cause(s) stated. (Signature and Tide) H K O 8 `o 9g. INSIDE CITY LIMITS El YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Daughter 16c. DATE (Mo., Day, Yr.) June 21, 2016 17t Zip:Code 68801 APPROXIMATE `INTERVAL onset to death 1 Week onset to death.. 2 Weeks onset to death STATE Nebraska onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? YES 511 NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E . 21d. WERE AUTOPSY FINDINGS AVAILABLE' TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO (;'street, factory, office building, construction site, etc. (Specify) P CORE 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED'? Not Applicable if 26a is NO. ❑ YES ❑ NO Day, Yr.„)