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STATE OF NEBRASKA 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 ate . DATE OF ISSUANCE 9/21/2017 LINCOLN, NEBRASKA 201707212 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DUE TO, OR AS A CONSEQUENCE OF: c) ZIP CODE' 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Robert Henry Clausen 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 506 -38 -694.6 8b. FACILITY -NAME WOO institution, give street and number) Good Samaritan Society -Grand Island Village 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 98: R - STATE Nebraska 9d. STREET AND NUMBER 5719 S. US Highway 281 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated', ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Henry Clausen 1.3. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or Utik.) No 15. METHOD OF DISPOSITION ®Burial ❑ Donation ❑ Cremation ❑ Entombment [3 Removal :;❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska 16. PART 1. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enterterminal 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. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Interstitial Lung Disease, Progressive Hypoxia disease or csndi: ion resulting in death) .. Setiuettially Nat •conditions, • any,teeding to the cause listed:. on line'a. Enter the UNDERLYING CAUSE (disease or mjurythat 1n0ate0.: the events resulting in death) •tAST• • 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Parkinson's Disease, 812 Deficiency, Memory Loss, Normal Pressure Hydrocephalus, Status Post Shunt W tJ 20. IF FEMALE: ;:.:. ❑ Not pregnant within pait year ❑ Pregnant at time of death Not WegO,nt within 42 days of death • ❑ Not pregna but :but pre 43 days to 1 year before death tlnkrlgwn if prognent wtttnn the past ye E 22a. DATE OF INJURY (Mo., Day, Yr.) O N 24,�iNJt1RY ATWORM? >. D YES Q NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN 23b. DATE SIGNED (MO., Day, Yr.) I i; E September 18, 2017 Y q 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 5 and due to the cause(s) stated. (Signature and Title) p . DATE OF DEATH' (Mo., Day, Yr.) September'10, 2017 Jane A. McDonald, MD DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES El NO ❑ PROBABLY ❑ UNKNOWN 23c. TIME OF DEATH 03:15 PM 5a. AGE ' Last Birthday (Yrs.) 89 9b. COUNTY Hall 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined bb. UNDER 1 YEAR MOS, 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9e. CITY' OR TOWN Grand Island 10b. NAME OF. SPOUSE (First, Middle, Last, Erma Buchfinck 16a. EMBALMER- SIGNATURE Katie M. Smvdra 12. MOTHER'S -NAME (First, Middle, Hulda Detlefsen 14a. INFORMANT-NAME Kenneth Lee Clausen 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island City Cemetery Grand Island CAUSE OF DEATH (See instructions and examples) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Sp DAYS HOURS 8d. COUNTY OF DEATH Hall 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY MINS. OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68801 16b. LICENSE NO. 1454 21b, IF TRANSPORTATION INJURY ❑f Driver /Operator ❑ Passenger 0 Pedestrian 0 other (Speciy) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) September 10, 2017 6. DATE OF BIRTH (M0.;:; Day, Yr,) December 1, 1927 Suffix) If wife, give maiden name Maiden Surname) ❑ Hospice Facility 9g. INSIDE CITY LIMITS ❑ YES ® NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) September 15,2017 A P P ROXIM ATE?I N TERVAL. onset to death Years STATE Nebraska 17b. Zip Code 68801 onset to death 19. WAS MEDICAL EXAMINER OR CORONER t �CONTACTED? ❑ YES ta,t NO 21c. WAS AN AUTOPSY PERFORMED? ❑YES (XI NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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 Tide) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES Ea NO I Not Applicable if 26a is NO ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 r. 28a, REGISTRARS SIGNATURE 28b. DATE FILED BY REGISTRAR (M September 18, 2017 Day, Yr.