|
yf
<br />trittitab k , air At
<br />STATE OF NEBRASKA
<br />IMigtv
<br />WHEN 4 THIS ''COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE 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 />8/11/2016
<br />LINCOLN, NEBRASKA
<br />2 Q 'v V
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Allan Christian Roemmich
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sutton, Nebraska.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -18 -7949
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />Oa. RESIDENCE -STATE
<br />Nebraska
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />13. EVER IN U.S.: ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes :; 03/26/1945-01/13/1947
<br />15. METHOD OF DISPOSITION
<br />J Burial 0 Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal CI Other {Specify)
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />© Not pregnant,; out pregnant43 days to 1 year before death
<br />❑ Vnknown 11 pregnant wdh'tnthe past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. ) NJURY AT WORK?
<br />❑ YES ❑ NO
<br />22b. TIME OF INJURY
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES NO ❑ PROBABLY ❑ UNKNOWN
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />93
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND NUMBER
<br />1208 North Howard
<br />16a. EMBALMER-SIGNATURE
<br />Christopher J. Loecker
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Coutd not be determined
<br />230. DATE OF DEATH (Mo., Day, Yr.)
<br />Ju.1y 24, 20t6
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 8, 2016
<br />23c. TIME OF DEATH
<br />07 :30 PM
<br />3d. 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 />Jay G. Anderson, MD
<br />28a. REGISTRAR'S SIGNATURE /j,r �- `� ,s
<br />I L E X ' �/P�"
<br />5b. UNDER 1 YEAR
<br />M
<br />QS.
<br />DAYS
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 24, 2016
<br />6. DATE OF BIRTH (MO,, Day, Yr.)
<br />June 30, 1923
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ® Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) I1 wife, give maiden name
<br />Elsie Purdy
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Adolph Roemmich
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Olga Rath
<br />14a. INFORMANT -NAME
<br />Elsie Roemmich
<br />16b. LICENSE NO.
<br />1421
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY /TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aotel Funeral Home. 1123 W. 2nd, Grand Island. Nebraska
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Parknsons, diabetes„ Cardiomyopathy,hypothyroidism
<br />230. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 Other(Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES iJ NO
<br />9f. ZIP CODE
<br />68803
<br />28b. DATE FILED BY REGISTRAI
<br />August 8, -2016
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP:: TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />July 27, 2016
<br />17b. tip Code
<br />68801
<br />CAUSE OF DEATH (See instructions examples)
<br />IS. PART I. Entertl!e chain of events- - diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or venttio filar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause: on a lined Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />a) Alzheimers Dementia
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />Years
<br />APPRO INTERVAL
<br />in death):
<br />Sequentially list dgitaitions, if
<br />any, leading to the cause lister{;
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />Enter the UNDERLYING CAUSE
<br />tdisease or injury that initiated.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />the eventsresulting'. In de
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES Q NO
<br />21c. WAS AN AUTOPSY PERFORMED ?::
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE DEATH ? .
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE'
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED 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 />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />
|