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delAtiattith, .A , . ; Aga Fat STATE OF NEBRASKA a e ; x l need E 0 U 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 201802449 DATE OF ISSUANCE 3/16/2018 LINCOLN, NEBRASKA 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Robert Charles Templin 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Stanton, Nebraska 7. SOCIAL SECURITY NUMBER 507 -22 -8297 8b. FACILITY -NAME (It not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE Nebraska 9d. STREET AND NUMBER 2424 W. John St. 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Peppy Colleen Larson 11. FATHER'S-NAME (First, Middle, Last, Suffix) Chales E Templin 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, or Unk.) Yes 07/24/1943- 05/23/1945 Peqqy Templin 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑:Removal ❑ Outer (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska CAUSE OF DEATH (See instrut Lions and examples 8. PART F. Enter the chain of events- -diseases, injuries, or complications-that directly caused tltie death. DO NOT enter tennmal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on alie. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Chronic Systolic Congestive Heart Failure disease or condition resulting in deathk... ........ . Sequentially list conditions, if any, leading to tha:�calms listed on linen Enter the UNDERLYING CAUSE (disease or injury :that i tittated the events resulting in death) LAST 22d, INJURY AT:WOAK? }, ❑YES ❑N4 U 0 r I 23a. DATE OF;DEATH (Mo., Day, Yr.) March 8.2018 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE! OF DEATH 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services DUE TO, OR AS A CONSEQUENCE OF: b)Coronary Artery Disease DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 20, IF FEMALE: ❑ Not pregnarttwithinpast year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, put prepnarf 43 days to 1 year before death iinknOwn it pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH March 12, 2018 11:48 PM 3d. To the bent of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jay.C. Anderson, MD 5a. AGE - Last Birthd (Yrs.) 93 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES p NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 J 28a REGI8TRAR S SIGNATURE 3- a Sb. UNDER 1 YEAR OS. DAYS 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island 9e. APT. NO. 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Alzheimers Dementia, Humerus Fracture, 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY/TOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? j STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 6b. LICENSE NO. Gibbon 6c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall CITY I TOWN 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 9f. ZIP CODE 68803 STATE 24c, PRONOUNCED DEAD (Mo., Day, Yr.) MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) September 1, 1924 Suffix) If wife, give maiden name 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Opal Wood ❑ YES El NO ❑ YES ❑ NO 24b. TIME OF DEATH 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 3. DATE OF DEATH (Mo., Day, Yr.) March 8, 2018 6. DATE OF BIRTH IMO., Day,Yr.) ❑ Hospice Facility 9g. INSIDE CITY LIMITS O YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse . 16c. DATE (Mo., Day, Yr.), March 12, 2018 STATE Nebraska J 17th Zip Code 68801 APPROXIMATE INTERVAL onset to death Years onset to dei Years onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES" El NO 21c. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE 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) 0 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 12, 2018