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<br />STATE OF NEBRASKA
<br />ISN
<br />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 IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />1/4/2017
<br />LINCOLN, NEBRASKA
<br />201807169
<br />ale
<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 />Robert Louis Siemers
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 22, 2016
<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 />Grand Island, Nebraska
<br />(Yrs.)
<br />72 -
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 25, 1944
<br />7. SOCIAL SECURITY NUMBER
<br />508-54-2584
<br />8a. PLACE OF DEATH
<br />HOSPITAL [] Inpatient OTHER U Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />5076 W Abbott Road
<br />0 ERlOutpatient ®Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />5076 W Abbott Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />0 YES I NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />❑ Married, but separated E Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Betty Joann Perkins
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Louie Siemers Ann Rauert
<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 />Marcia Renee Bartels
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />December 27, 2016
<br />® Cremation 0 Entombment
<br />❑ Removal 0 other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING 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 />4a. PART I. Enter the wham of events- -diseases, injuries, or complications -that directly caused the death. DO' NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest of 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 />1 IMMEDIATE CAUSE (Final 3) unknown Natural Cai, es
<br />disease or condition resulting
<br />onset to death
<br />in death} DUE TO, OR AS A CONSEQUENCE OF: -
<br />Sequentially Ilet condltiOn8, if - b)Respiratory Failure
<br />any, leading to the cause hated
<br />onset to death
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Myocardial Infarction
<br />disease or injury that initiated
<br />onset to death
<br />the events resultinglin death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST;
<br />d) Stroke
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Diabetes; Prostate Cancer; Advanced Age
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ENO
<br />20. IF FEMALE:
<br />0 Not pregnant Within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />IDPassenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 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 />o unknown if pregnant within the past year
<br />0 0
<br />❑ Suicide Could be determined 0ounot ne
<br />❑Pedestrian
<br />❑Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABL:
<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 />❑ YES ❑ NO
<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 OF DEATH (Mo.. Day. Yr.1
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNE
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />December 27, 2016
<br />24b. TIME OF DEATH
<br />Approx. 10:00 PM
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />December 23, 2016
<br />24d. TIME PRONOUNCED DEAD
<br />10:47 AM
<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 />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 causes) stated. (Signature and Title)
<br />S. Alex West, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY E UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES El 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 />S. Alex West, Hall Deputy County Attorney, 231
<br />S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />128a. REGISTRAR'S SIGNATURE - C _ _
<br />i(_7`{li)DftJ/ /V
<br />28b. DATE FILED BY REGISTRAR (Mo, Day, Yr.) ,
<br />December 28, 2016
<br />
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