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-caoi tt 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 12/12/2016 LINCOLN, NEBRASKA 201905329 cop STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Robert R Brown 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) April 30, 2016 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Hall County, Nebraska (Yrs.) 78 MOS. DAYS HOURS MINS. November 7, 1937 7. SOCIAL SECURITY NUMBER 507-48-6570 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis E ER/Outpatient ❑ Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE 19b. COUNTY 19c. CITY OR TOWN Nebraska I Hall I Doniphan 9d. STREET AND NUMBER 202 East Pine 9e. APT. NO. 9f. ZIP CODE 68832 9g. INSIDE CITY LIMITS ® YES 0 NO 10e. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married Married, but separated 0 Widowed 0 Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Gloria Lenz 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ralph R Brown Mabel Gerdes 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yea. (Yes, No, or link.) Yes 1958-1960 14a. INFORMANT -NAME Gloria Brown 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION E Burial 0 Donation 16a. EMBALMER -SIGNATURE Gwen K. Hyronemus 16b. LICENSE NO. 1448 16c. DATE (Mo., Day, Yr.) May 7, 2016 ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Rosedale Cemetery Rosedale Nebraska 17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) Livingston-Butler-Volland Funeral Home. 1225 N. Elm. Hastinas. Nebraska 17'b,ZipCode 68901 I ;, CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. 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, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiac Arrest, Ventricular Fibrillation d?sears or condition resoni'+c onset to death hours In death) DUE TO, OR AS A CONSEQUENCE OF: - Sequentially list condition*,it : b)Tobacco Use, Diabetes Type 2, Hypertension, any, leading to the reuse listed onset to death Years on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or inpiry+hs• i"ltimrd< onset to death the events resulting in death) 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. Chronic Myelogenous Leukemia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E YES ❑ NO 20. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of deathPassenger 21a. MANNER OF DEATH E Natural 0 Homicide Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 21c. WAS AN AUTOPSY PERFORMED? 0 YES ENO 0 Not pregnant, but pregnant within 42 days of death❑ 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 0 Suicide 0 Could not be determined ❑ Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE 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 YES WORK? ;; ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 9 g 23a. DATE OF DEATH (Mo., Day, Yr.) April 30. 2016 e } 2 5 i 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH Y Y 1 u z 23b. DATE SIGNED (Mo., Day, Yr.) May 4, 2016 23c. TIME OF DEATH 12:28 AM i _ g T I N< o 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 3d. To the best of my knowledge, death occurred at the time, date and place a g a and due to the cause(s) stated. (Signature and Title) r x Jane A. McDonald, MD w z . Q u ~ r8 a 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) 95 Dtn TPP CC' USE Com'! ...:..,.. i TO Ti is DEATH? zoa. nAS ORGAN. OR TISSUE' DONATION BEEN CONSIDERED? ® YES 0 NO 0 PROBABLY 0 UNKNOWN I ❑YES ®NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ED YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a, REGISTRAR'S SIGNATURE ,_ arcrip iv { ��p�� 28b. DATE FILED BY REGISTRAR(Mo., Day, Yr.) May 6, 2016