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VOX
<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 />og
<br />DATE OF ISSUANCE
<br />9/10/2018
<br />LINCOLN, NEBRASKA
<br />201903699 RUSSELL FOSLER
<br />INTERIM 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 />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceasec 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 />Robert Clinton Whaley
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 25, 2018
<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 />Kearney, Nebraska
<br />(Yrs.)
<br />77
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />August 26, 1940
<br />7. SOCIAL SECURITY NUMBER
<br />519-40-0971
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />18d. COUNTY OF UEATI-i
<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 />2105 N Engleman Rd
<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 ® Married ❑ Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Peggy Garner
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) :
<br />Guy Hobart Whaley
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Laura Elliot
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, NO, Or Unk.) Yes 05/18/1962-04/01/1965
<br />14a. INFORMANT -NAME
<br />Peggv Whaley -
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE 116b. LICENSE NO.
<br />Stacie L. Ruiz 1495
<br />16c. DATE (Mo., Day, Yr.)
<br />August 30, 2018
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG 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 />15. PART 1. Enter the chain of events- -diseases, injuries, or complications4hat directly caused the death. 00 NOT enterte,minsl 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 addition& lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Mesothelioma
<br />disease or condition resulting
<br />onset to death
<br />Prior
<br />death:
<br />DUE TO, OR ASA CONSEQUENCE OF.
<br />Sequentially list conditions, if b) Health Care Associated Pneumonia
<br />any, leading to the cause listed.
<br />line
<br />=s.. tc_.p
<br />Days
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C) Acute Hypoxic Respiratory Failure
<br />(disease or injury that initiateti.
<br />onset to death
<br />Days
<br />the eventsresulhng m death) ", DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)Pleural Effusions
<br />onset to death
<br />Weeks
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Mesothelioma And Respiratory Failure And Transitioned To Comfort Care And Passed Away At Hospital
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YES E]
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />21a. MANNER OF DEATH :
<br />® Natural ❑ Homicide
<br />ti
<br />❑ Accident El Pending Investigaon
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<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 />0 Unknown ifpregnant within the past year
<br />0 Suicide 0 Could not be determined
<br />❑ 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 ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed DJ:'>'
<br />MEDICAL CERTIFIER...
<br />ONLY
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />Auqust25,2018
<br />To be completed ty
<br />CORONERS PHYSICIAN
<br />of COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />3b. DATE SIGNED (Mo., Day, Yr.)
<br />2)
<br />August 28, 2018
<br />23c. TIME OF DEATH
<br />10:49 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<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 />Michael A. Danner, MD
<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 />0 YES E NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR ISSUE s • ATION 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 />Michael A. Donner, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />•�
<br />28b. DATE FILED BY REGISTRAR (MO., Day, Yr.)
<br />September 5, 2018
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