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A.
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRINE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />3/15/2
<br />LINCOL NEB RASKA
<br />201801923
<br />j
<br />STANLEY COOPER
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Earl Robert Renner
<br />4. CITY•AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Madison Ctauhty,;Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-48-0326
<br />b. FACILITY -NAME (Knot Institution, give street and number)
<br />Tiffany Square Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE•STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2012 N. Grand Island Ave
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑,Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. PATHER'S•NAME (First, Middle, Last, Suffix)
<br />Robert Renner
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Clara Reeg
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) NO
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removat ❑ Other(Specify)
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska
<br />CAUSE OF DEATH,ISee instructions and examples)
<br />1S. PART I. i=nter the chain of events- -diseases, Injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, of ventricular fibrillation without shgwing the etiology. DO NOT ABBREVIATE. Enter only one cause on a lute. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a)Advanced Alzheimers Dementia
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />1 Oyears
<br />in death}
<br />Sequentially list conditions, it
<br />any, Matting to the cause listed
<br />on line a - - -'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20.3E =FEMALE:
<br />❑ Not pregnantwithin past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Uflknown 0 MM within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />}� March 31, 2015
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<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />23b, DATE SIGNED (Mo., Day, Yr.)
<br />April 1, 2015
<br />28a. REGISTRAR'S siGNATURE
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />93
<br />9b. COUNTY
<br />Hall
<br />22b. TIME OF INJURY
<br />23c. TIME OF DEATH
<br />08:20 AM
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ inpatient
<br />❑ EIRIOUtpatient
<br />❑ DOA
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />10b. NAME OF SPOUSE (First,. Middle, Last, Suffix) If wife, give maiden name
<br />Marcella Ester Hofmann
<br />14a. INFORMANT -NAME
<br />Marcella Ester Renner
<br />16a. EMBALMER - SIGNATURE
<br />Katie M. Smvdra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />St. John's Lutheran Cemetery
<br />CITY /TOWN
<br />Battle Creek
<br />STATE
<br />Nebraska
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Richard Freehling, MD
<br />9c. CITY OR TOWN
<br />Grand island
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />21b. IF TRANSPORTATION
<br />❑' Driver /Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other(Specify)
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />2d.INJURY ATVVORK?
<br />❑YES ❑NO '.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES NO
<br />24a DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOU
<br />ED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Richard Freehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 31, 2015
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 5, 1921
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />16b. LICENSE NO.
<br />1454
<br />INJURY
<br />9g. INSIDE CITY LIMITS':
<br />® YES ❑ NO
<br />14b. RELATIONSHIP.TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />April 2, 2015
<br />17b.Ztp Code
<br />68801
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES : RI NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 1E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH? >.
<br />0 YES NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 6, 2015
<br />26b. WAS CONSENT GRANTED? 0 Not Applicable if 26a is NO ❑ YES 0 NO
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