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1. DECEDENT'S -NAME (First, Middle, Last, •• • ` v• Suffix) ^, „ Robert Loren Collinson 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) January 25, 2009 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Akron, Ohio 5a. AGE -Last Birthday (Yrs.) 59 5b. UNDER 1 YEAR 5c, UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) January 18, 1950 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 283-48-5976 8a. PLACE OF DEATH HOSPITAL: K] Inpatient Q]}:166 ❑ NursingHome/LTC O Hospice Facility ❑ ER /Outpatient ❑ Decedent's Home ❑ CO4 ❑ Other(Specify) 8b. FACILITY -NAME (It not institution, give street and number) St. 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 9c. CITY OR TOWN Doniphan -- Grand Bien 9d. STREET AND NUMBER Ve• 108 West Bartelt 9e. APT. NO 9f. ZIP CODE 68832 9g. INSIDE CITY LIMITS Xp YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH Itl Married ❑ Never Mauled ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Sara Grovas 11. FATHER'S -NAME (First, Middle, Last, Suffix) Richard Collinson 12. MOTHER'S -NAME (First, Middle, Malden Surname) Mary White 13. p EVER IN U.S. ARMED FORCES? Give dates of service If yes. (YeY' o?unk.) / 2 / 1969 4/16/1971 14a. INFORMANT -NAME Sara Collinson 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION CXBurial ()Donation O Cremation ❑ Entombment a, ❑ Removal ❑ Other (Specify) 16a. E ER -S AT E 16d. CEMETERY, CR ORY OR OTHER LOCATION Cedarview Cemetery 16b. LICENSE NO. /2 f CITY /TOWN Doniphan, Nebraska 16c. DATE (Mo., Day, Yr. ) January 28, 2009 STATE 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 West Second, Grand Island, NE. 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, APPROXIMATE respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: I ,/ /`' f onset IMMEDIATE CAUSE (Final (a) l /�7 %,'(� /f( /� irre 17b. Zip Code 68801 INTERVAL to death diseaseorcondidon resulting DUE TO, OR AS A CONSEQUENCE OF: onset to death in death) _ , Sequentially list conditions, 8 (b) C - . j - , y cs,� , any, ladingtothecauselisted 1r /� DUE TO, OR AS A CONSEQUENCE OF: on line a. onset to death Enterthe UNDERLYING CAUSE // (disease or Injury that In Initiated (c) //eel ile N�/�,a�ii �� , -/f = theevams resultin in death) , / EO [[[ „Ii �(/��1�'G�i.. /'c''� " f�lJ 4 ,�/J`C�/'G 9 DUE TO, OR AS A CONSEQUENCE OF: F onset to death LAST l (d) C oi. - /76-!''/ 4 /i5, -,' '4- 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions con ting to the death bu of resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? O YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year ❑P Pregnant at time of death 9 ❑ 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 21a..M,�ANNEROFDEATH L-- XY Natural ❑Homicide ` ❑ A ccident❑ Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑Pasen Passenger ❑Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ��......,,,((( ❑ YES q(1 NO ✓ ! 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES )4N0 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE u1?5 A's F Y = y o � c 23a. DATE OF DE TH (Mo., D Yr.) 1 ' Lc ( Z y > M _ 4 E p `_ e s t 8 51 k C! E ¢ 0 § `o 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH m 23b. DATE SIGNED (Mo., Da Yr.) J alcuary 28, 2009 23c. TIME OF DEATH '-' O()15 m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To t of ray knowledge, death occur ed- a time, date and place t/ and du the causes) otaled. (Signs e ea/ and Title ) ♦� . p 24e. On the basis of examination and /or investigation, the time, date and place and due to the In my opinion death occurred at causes) stated. (Signature and Title ) • 28 DID TOBACCO USE CONTRIBUTE TO THE DEATH? v' ❑ YES / , Q� 1 / NO ❑PROBABLY 0 UNKNOWN 26a. HA .ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES Lt V s 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TI ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COU ATTORNEY) (Tope or Print) Erich Fruehling M.D. 3515 Richmo d cle, Grand Island, NE' 68803 28a. REGISTRAR'S SIGNATURE 06, 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) JAN 3 0 2009 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTJ4 AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA •DEPARTM,ENT HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY'fop.VITAL +RECoRoS.: DATE OF ISSUANCE FEB 19 2009 LINCOLN, NEBRASKA 2010580 StmLE.Y S 0OPE}� AS. STANT STATE REGISTRAR ;DEPARTMENT OF HEALTH AND �-lUl�lAl115ERVICESa , STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOI HHS -61 11/03 (55061)