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WHEN'' 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 /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />3/21/2017
<br />LINCOLN, NEBRASKA
<br />Cow
<br />STANLEY S. COOPER
<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 />To be completed/verified by: FUNERAL DIRECTOR
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Duane Robert Einspahr
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 11, 2017
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Anselmo, Nebraska
<br />(Yrs.)
<br />61
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />April 18, 1955
<br />7. SOCIAL SECURITY NUMBER
<br />507-74-5495
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />Sb. FACILITY -NAME (N not Institution, give street and number)
<br />319 East 18th
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DOA ❑ Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d. COUNTY OF DEATH
<br />I Hall
<br />9a. RESIDENCE -STATE COUNTY
<br />Nebraska 19b.
<br />Hall
<br />9c. CITY OR TOWN
<br />I< Grand Island
<br />9d. STREET AND NUMBER
<br />319 East 18th
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated'' ❑ Widowed ❑ Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Nancy Sue Walker
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Einspahr
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Rita Fitzsimons
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Nancy Sue Einspahr
<br />14b. RELATIONSHIP. TO DECEDENT
<br />Wife
<br />15. METHODOF DISPOSITION
<br />® Burial ❑Donation
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />166. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />March 17, 2017
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other(Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<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 />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples/
<br />To be completed by: CERTIFIER
<br />18. PART I. Eller the Chain oI events --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL:
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />rtiseace or condition resulting
<br />onset to death
<br />Immediate
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: .
<br />sequentialty list conditions, if b) Myoca rdial Infarction
<br />any, leading to the cause fisted
<br />linea. - -
<br />onset to death`
<br />Immediate
<br />on
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Congenital Heart Disease
<br />(disease or injury that initiated
<br />onset to death
<br />Years
<br />theevents resultingin death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of deathPassenger
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant wdhin the past year
<br />0 Suicide Could: not be determined
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />OYES 0NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE Cr DEATH (Mc., Day, Yr.)
<br />To be completed. by
<br />CORONER'S PHYSICIAN
<br />of COUNTY ATTORNE`:
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />March 16,2017
<br />24b. TIME OF DEATH
<br />Approx. 10:45 AM
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />March 11, 2017
<br />24d. TIME PRONOUNCED DEAD
<br />11:45 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />24e. On the basis of examination and/or investiga ion, in my opinion death occurred at
<br />the time, date and place and due to the causes) stated. (Signature and Title)
<br />Kate Collins, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES I NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kate Collins, Hall. Deputy County Attorney, 231
<br />S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a, REGISTRAR'S SIGNATURE /1� ii-
<br />28b. DATE FILED BY REGISTRAR No., Day, Yr.)
<br />March 16, 2017
<br />
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