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�xxn„rw, ra1174 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 8/13/2018 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 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased a*e filed with the county court in the county where the decedent resided at thF time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Robert Gerald Williams 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) September 7, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska {Yrs.) 77 MOS. DAYS HOURS MINS. June 16, 1935 7. SOCIAL SECURITY NUMBER 505-38-5565 8a. PLACE OF DEATH HOSPITAL E Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Francis Medical Center 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) _ _Saint 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE = Nebraska : 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1315 W. 7th St. 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS EI YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown 10b. NAME. OF SPOUSE (First, Middle, Last, Suffix) tf wife, give maiden name Rachael Louise Jacobsen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Charlie Williams 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dorothy Powell 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 05/14/1958-05/13/1960 14a. INFORMANT -NAME Rachael Louise Williams 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑'Burial ❑Donation 16a. EMBALMER -SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) September 12, 2012 ® Cremation 0 Entombment ❑.Removal 0 Other (Specify) 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) 111. PART 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 respiratory arrest, of ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Intercranial Hemorrhage disease or to"ditinn revolting onset to death Days in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, it < b)Anticoagulation any,: leading t0 the cause listed on line a. onset to death Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C)Atrial fibrillation, Thromboembolism Prophylaxis (disease or injury that initiated onset to death Years the events resulting in loath) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Dementia, Peripheral Vascular Disease, Tobacco Abuse, Hypertension 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®`NO 20. IF FEMALE: = 0 Not pregnam within past year 0 Pregnant at time of death 21a. MANNER OF DEATH ', E Natural ❑ Homicide 0 Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ® NO n El Not pregnant, 0 Not ptegnant, 0 Unknown If but pregnant within 42 days of death but pregnant 43 days to 1 year before death pregnant within the past year 0 SuicideCould not be determined ❑ 0 Pedestrian o Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABL= TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., 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 0NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be competed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) September 7, 2012 0 6 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) ' Seetember 11 2012 23c. TIME OF DEATH $ 1. -i Y 12:42 PM E.N a z 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD r 3d. To the best of my knowledge, death occurred at the time, date and place 'o' w z O and due to the cause(s) stated. (Signature and Title) 0 0 gO ccU Jav C. Anderson, MD i -o .8 ta 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 Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES '® NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑'YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /lam / jej_ ~ , 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 11, 2012