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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 IS THE LEGAL DEPOSITORY FOR VITAL RECORDS x,
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />5/3/2019
<br />201902765
<br />201903488
<br />LINCOLN, NEBRASKA
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceasid 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 />Keith Arden Fischer
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 15, 2019
<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 />Geddes, South Dakota
<br />(Yrs.)
<br />76
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 8, 1942
<br />7. SOCIAL SECURITY NUMBER
<br />503-46-8498
<br />8a. PLACE OF DEATH
<br />HOSPITAL E Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />+ f not It ution. -gi
<br />.ve street and number}
<br />8h. . T Y ,. F. Ir-
<br />Nlary LBnntng rteaitncare
<br />f`I EP/Ol,tpatier +
<br />0 no,„f . ❑ Decedent's Home
<br />r Other iSPa 1 V;
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Hastings 68901
<br />8d. COUNTY OF DEATH
<br />Adams
<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 />409 Takewood Cr.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Jane Nolan
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Wilbert Fischer
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Alyce Hyde
<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 />Jane Fischer
<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 17, 2019
<br />®Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Crematory Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livinaston-Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska
<br />17b., Zip Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />Ia. PART I. Enter the chain 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, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a/ Adult Failure To Thrive
<br />:ase Of c ak.or. raeu.tillg
<br />onset to death
<br />Weeks
<br />in death)
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />Sequentially list conditions, if b)Advanced Alzheimer's Type Dementia
<br />any, leading to the cause listed'
<br />onset to death.
<br />Years
<br />on line a.
<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 />lite events resubmit in 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 />0 YES E NO
<br />20. IF FEMALE:
<br />❑ 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 />❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES E NO
<br />❑ Not pregnant, OW pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown 4 pregnant within the past year
<br />❑
<br />❑ Suicide Could 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 />OYES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be compleo:d by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />ca :Alt ur ,T ^ 7c;, Y7.; 1 .
<br />April 15 2019 I : It ziu
<br />24a. DATE SIGNED (Mo., Day, Yr.) 124b. TIME OF DEATH :.
<br />I
<br />WD. DA ra StGNE %MD., Day, -r!.j
<br />April 18, 2019
<br />... ,.. ":_:..' D-:�:T;i
<br />08:50 PM 1
<br />:, m O
<br />n
<br />o n a
<br />o
<br />.. PR- hiC1 .:f, ncAC I,tln n,,, vr,, 24d. TIME PPnkinUNr.ED DEAD
<br />_ _.
<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 />Daniel B. Einspahr, MD
<br />„
<br />w z
<br />g 0 p
<br />-o:V
<br />$ s
<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 />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES E NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E 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 />Daniel B. Einspahr, MD, 715 N Saint Joseph Ave,
<br />Hastings, Nebraska, 68901
<br />28a. REGISTRAR'S SIGNATURE :
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) z I
<br />April 29, 2019
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