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- 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Ernest Leonard Dobesh 2. SEX" t 1 (7.. Male 4. DIM 0F DEATH (Mo.,Day,Yr.) Aprif2.1, 2008 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Clay County, Nebraska 5a. AGE -Last Birthday (Yrs.) 86 5b. UNDER 1 YEAR 5c. UNDER 1 DAY "6. DATE OF BIRTH (Mo., Day, Yr.) July 31, 1921 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508- 14-7309 8a. PLACE OF DEATH }1OSPITAki ® Inpatient OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home 0 DOA ❑other(specity) 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical 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 9e. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1533 Stagecoach Road 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® 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. Wilma Bangert 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Dobesh 12. MOTHER'S -NAME (First, Middle, Malden Surname) Mary Barta 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, orUnk.) Yes 10/03/1942- 10/03/1945 14a. INFORMANT -NAME Wilma Dobesh 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Banal ❑Donation ❑Cremation ❑Entombment ❑Removal ❑Otlrerlepectly) 16a. EMBAL RSIGNALl1RE • IAA H] d 16b. LICENSE NO. /Z l 7 16c. DATE (Mo., Day, Yr.) April 26, 2008 CEMET Westlaw RY, CREMATORY OR OTHER LOCATION CffY/TOWN STATE Memorial Park 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 complications- that directly caused the death. DO NOT enter terminal events such as cardiac arrest, I APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE Enter only one cause on a fine. Add additional lines x necessary. IMMEDIAT USE: ' diseease ase o or condition resua l lting a) / / r onset to death y IM CAUSE ( Fin _ ` / • A n 1 ' . t�' r ' ,y wlc --�-- / in death) �' ", J � � • NSEQUENCE OF: ' • ./f I onset to des h DUE TO, OR AS A b) l / r�I / I r Sequentially list conditions, If �-�� -' -�� any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death I Enter the UNDERLYING CAUSE c) I (disease or injury that Initiated 1 '' the events retuning In death) CE ., 0, OR AS A CONSEGUEt' E Orr or.aat ir; Jsatt. LAST I I d) 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART 1 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ vas lio 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 21 ANNER 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 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES j / NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, fans, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT V1{ORK? ❑ YES U ! / NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE IO a < d W E E12-21 o Imo • F Q 23a. DATE OF DEATH (Mo., Day, Yr.) April 21, 2008 Z .00z ,a,! > C O >- 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23b. DATE ' NED (Mo., Day, Yr.) M a 9 2008 23e. TIME OF DEATH 9:55 pent, 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) rc• 23d. o the b f my knowledge, de occurre at the time, date and place u W Z I e - use(s) a nature an ) o O U 0 o \ 25. DID TO ❑ YES "'. USE CONTRIBUTE TO THE DEATH? l�l NO ❑ PROBABLY ❑ UNKNOWN 28a. HAS ORGAN OR ON BEEN CONSIDERED? ❑ YES • • • 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES R1 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) John Wagoner M.D., 800 Alpha St., Island, Nebraska 68803 28a. REGISTRAR'S SIGNATURE P ' ' 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) MAY 1 2 2008 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SgR VICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD O01LE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS. SECfO 'b,.WFItCM'I THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAY 1 4 2008 LINCOLN, NEBRASKA 201608463 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S CE OF DEATH �a TAME) S. COOPE A ASSISTANT StA`f RSG!ST1 A7� HEALTH,AND HUMAN SERVIC