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Pursuant to section 30 -2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Robert Lee Kreider Sr 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) August 25, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Roseland, Nebraska 5a. AGE - Last Birthday (Yrs.) 84 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) December 3, 1933 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -36 -3787 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility ab. FACILITY -NAME Of not Institution, give street and number) Park Place -A Golden Living Center ❑ ER/Outpatient ❑Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH I Hall 9a. RESIDENCE -STATE `` Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3135 N. St. Paul Rd 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated 0 Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Susie Enevoldsen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Linus Tianer Kreider 12. MOTHER'S -NAME (First, Middle, Maiden Surname! Estella May Smith 13. EVER. IN U.S. ARMED FORCES? Give (Yes, No, or Unk.) Yes 12/07/ dates of service if Yes. 956- 12/06/1962 14a. INFORMANT -NAME Susie Kreider 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑Donation El Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) August 28, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1 8. PARY 1, Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL cause on a late. Add additional lines R necessary. onset to death 6 Months respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Metastatic Melanoma To Brain And Lung disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death ' Seeluennally hat cootladons, If : b) any, leading to the cause listed a. on line DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated the evems resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset t0 death LAST d) . PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES ®NO 20. ': ,LJ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unlmavn if pregnam within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver /Operator Passenger ❑ ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY ('do., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? < ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) August 25' 2018 > d i o II o a 1 � i c p ~ o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) August 28, 2018 23c. TIME OF DEATH 05:40 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD '. To •he best of my knowledge. death occurred at the time, date and place d and due to the cause(s) stated. (Signature and Title) Richard Fruehling, MD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and piece and due to tne cau eis/ s.atea. i3lgname ....: T::Ie) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E] NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE yy ..0 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 30, 2018 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 DATE OF ISSUANCE 9/5/2018 LINCOLN, NEBRASKA RUSSELL FOSLER DEPARTMENT HEALTH AND INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH