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14X STATE OF NEBRASKA ui 0 V 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 294193; j e 9/21/2017 " � � i LINCOLN, NEBRASKA 1. DECEDENTS - 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 -6946 b. FACILITY -NAME Of not Institution, give street and number) Good Samaritan S ociety -Grand Island Village 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 Ixa. RES1DENCESTATE Nebraska 9d. STREET ANDS NUMBER 5719 S. US Highway 281 lea. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Married, but separated RI Widowed ❑ Divorced ❑ Unknown Erma Buchfinck 11. FATHER'S-NAME {First, Middle, Last, Suffix) Henry Clausen a. 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. u (Yes, No, or Link.) No Z 15. METHOD OF DISPOSITION ® Burial 0 Donation ❑ Cremation ❑ Entombment ❑ Removal 0 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 15. PART 1. Eflt 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 H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Interstitial Lung Disease, Progressive Hypoxia u.siaSa 4-r c4r4 4 :Vii r69Uih44 in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially het conditions, if b) any, leading lb the cause listed on line a, DUE TO, OR AS A CONSEQUENCE OF: d. INJURY ATV/0 YES ❑ NO d) 14a. INFORMANT-NAME Kenneth Lee Clausen 16a. EMBALMER-SIGNATURE Katie M. Smvdra 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery Enter the UNDERLYING CAUSE c) (disease er *try :Oat iniSiered. the evi msresuxtny to death) .i,, DUE TO, OR AS A CONSEQUENCE OF: titer ::% 18. PART 11. 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 0.IPfEMALE: ❑ Not ptegnam pv thm past year ❑ Pre at time of death Dail hot pre gnant ;;but pregnam within 42 days of death Nat pregnam, abut pregnant 43 days to 1 year before death ❑ Unknown dgregnaiit kwttan the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22.. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN 3a. DATE OF IEATH (Mo., Day, Yr.) Sebte:nbet €10, 2017 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH September 18, 2017 03:15 PM d. To the best of my knowledge, death occurred at the time, date and place and due to the bauee(s) stated. (Signature and 'Title) Jane A. McDonald, MD 8a, REGISTRAR`S SIGNATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 5a. AGE • Last Birthday (Yrs. ) 89 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9b. COUNTY 9c. CITY OR TOWN Hall Grand tsland CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Couldinot be determined MOS 0.a a z W 2 � gz3 H:C U 0R 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 5b. UNDER 1 YEAR DAYS 1454 16b.LICENSE NO. STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 5c. UNDER 1 DAY HOURS CITY f TOWN Grand Island 24a. DATE SIGNED (Mo., Day, Yr.) MINS. OTHER ® Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH Hall 9e. APT. NO. 9f. ZIP CODE 68801 21b. IF TRANSPORTATION INJURY El Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) Cote 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Hulda Detlefsen 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) September 10, 2017 6. DATE OF BIRTH (Mo. Day December 1, 1.927 ❑ Hospice Facility I 9g. INSIDE CITY LIMITS' ❑ YES ® NO 14b. RELATIONSHIP, TO DECEDENT. Son 16c. DATE (Mo., Day; Yr.) September 15, 2017 ❑ YES ❑ NO STATE Nebraska 17b. ,Zip Code 68801 AP PROXIMATEINTERV onset to.*** Years onset to death': onset to death onset t# death' 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSEOF DEATH? 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) STATE "ZIP CODE 24e. On the basis of examination andlor investiga ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 2 5. DID TOBAGCD USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED*/ 26b. WAS CONSENT GRANTED? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN ❑ YES j NO Not Applicable if 26a is NO ❑ YES 28b. DATE FILED BY REGISTRAR 1Mtt., Day, Y September 18, 2017 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD ❑ NO