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<br />STATE OF NEBRASKA
<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 />5/2/2019
<br />LINCOLN, NEBRASKA
<br />201902969 ASSISTANT STATE REGISTRAR
<br />RUSSELL FOSLER
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />19 05337
<br />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.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Roger Allan Cline
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 19, 2019
<br />4. CITY
<br />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 />Lincoln,
<br />Nebraska
<br />(Yrs.)
<br />72
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />May 2, 1946
<br />7. SOCIAL SECURITY NUMBER
<br />505-54-4222
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />4148 Iowa lAvenue
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />Sc. CITY OR TOWN G,' iii A T H (Include Zip Cade)
<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 />4148 Iowa Avenue
<br />9e. APT. NO. 19f. ZIP CODE 1 9g. INSIDE CITY LIMITS
<br />I 68803 I ® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Elizabeth Ellen Peterson
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Samuel Cline
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ada Mae Mark
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 11/07/1966-09/30/1968
<br />14a. INFORMANT -NAME
<br />Elizabeth Ellen Cline
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<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 />April 20, 2019
<br />® Cremation 0 Entombment
<br />0 Removal ❑ 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 MA LING ADDRESS (Street, City or Town, State)17b.
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />Zip Code
<br />I 68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, injures, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />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) Metastatic Esophageal Cancer
<br />disease or condition resulting
<br />onset to death
<br />Weeks
<br />n death)
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to Ow cause listed
<br />on line a.
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onset to death
<br />the evems rasukcng or death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<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 />Cachexia
<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 death
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant. but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />0 Suicide 0 Coutd not be determined
<br />0 Pedestrian
<br />❑ 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 />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />7o be corneleted by
<br />..:MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 19, 2019
<br />repleted by
<br />i PHYSICIAN
<br />(ATTORNEY
<br />INLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Aprii 19/ 2019
<br />23c. TIME OF DEATH
<br />i 09:43 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. 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 />Chad Vieth, MD
<br />8 wz u
<br />e 2 p
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<br />U
<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 />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Ma., Day, Yr.)
<br />April 29, 2019
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