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< 0",","/ STATE OF NEBRASKA sau,d ' ism, I ,. st a 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 10/7/2016 LINCOLN, NEBRASKA 201608850 age STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH I- 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Roland Eric Westerby 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Camden, New Jersey 7. SOCIAL SECURITY NUMBER 142 -34 -7549 8b. FACILITY -NAME (If not Institution, give street and number) Nebraska ( Medicine' 9a. RESIDENCE -STATE Nebraska 1 MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑; Married, butt separated ❑ Widowed ❑ Divorced ❑ Unknown Last, Suffix) 1 EVER IN U.S -ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION ❑' Burial ❑ Donation Cremation ❑ Entombment ❑ Removal ;> ❑ Other (Specify) IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Sepsis - dtavese or cone.:Son ra_aY.ing in death) Sequentially list conditions, if b) Bowel Obstruction any, leading to the Cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) (disease or Injury that initiated 4he evems res ulting to death) DUE TO, OR AS A CONSEQUENCE OF: :Aar d) µ. 20. IF FEMALE: ❑ Not pregnant withm peat year 14.1 ❑ Pregnant at time of death , _[J Not pregnant, but pregnant within 42 days of death ❑ Not pregnant,Upt pregnant 43 days to 1 year before death ❑ Unknown it pregnant withitcthe past year E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 t) 42 :: 22d. INJURY AT WORK? 0 - ❑YES [3 NO 23a. DATE OF DEATH (Mo., Day, Yr.) September 28, 2016 23b. DATE SIGNED (Mo., Day, Yr.) October 3 2016 REGISTRAR'S SIGNATURE 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Not Embalmed DUE TO, OR AS A CONSEQUENCE OF: 22b. TIME OF INJURY 8 R § a O r 3d. To the hest of my knowledge, death occurred at the time, date and place G and due to the cause(s) stated. (Signature and Title) ~ g John D. Dickinson, MD 5. pip TOBACCO USE:CONTRIBUTE TO THE DEATH? ❑ YES 10 NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) 73 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23c. TIME OF DEATH 10:50 PM 5b, UNDER 1 YEAR MOS. 9d. STREET AND NUMBER 218 Ponderosa Drive DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 68198 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand Island 9f. ZIP CODE 68803 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Janis Schreiner 11. FATHER'S -NAME (First, Middle, Roland Westerby 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Charlotte Trout 14a. INFORMANT -NAME Janis Westerby 8d. COUNTY OF DEATH Douglas 16b. LICENSE NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Crematory CITY / TOWN Grand Island STATE Nebraska 17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livinoston Sondermann Funeral Home, 601 N. Webb Road. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) 1 &. 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, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line.: Add additional lines if necessary. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Acute Kidney. Injury 21b, IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 3. DATE OF DEATH (Mo., Day, Yr.) September 28, 2016 6. DATE OF BIRTH (Id , Day, Yr.) November 25, 1942 9g. INSIDE CITY LIMITS YES ❑ NO 14b. RELATIONSHIP, TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) October 3, 2016 17b. Zip Code 68803 onset to death 14 Days APPROXIMATE INTERVAL onset to deg 7 Days onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 21c. WAS AN AUTOPSY PER FORMED? ". YES ❑ NO 21d. WERE AUTOPSY FIINDIINGS AVAILABLE TO COMPLETE CAUSE DEATH? ❑ YES NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES I NO 24b. TIME OF DEATH .. 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investiga ion, 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 ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) John D. Dickinson, MD, 985910 NE Medical Center, Omaha, Nebraska, 68198 28b. DATE FILED BY REGISTRAR October 5, 2016 <, Day, Yr.)