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<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,
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISSUANCE
<br />9/10/2019
<br />LINCOLN, NEBRASKA
<br />amonded
<br />201908201
<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 />VITAL
<br />. DECEDENT'S -NAME (First. Middle, Lest, Suffix)
<br />James Allen Obermlller
<br />4.. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />I 7. SOCIAL SECURITY NUMBER
<br />v . 595-56-5103
<br />1i
<br />Ga. AGE • Last Birthday
<br />(Yrs.)
<br />73
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />E ERiOutpetient
<br />000e
<br />et
<br />N
<br />n
<br />9
<br />8b. FACIUYY•NAME Of net Institution, give street and number)
<br />CHI Health St. Francis
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 15, 2019
<br />B. DATE OF BIRTH (Ma, Day,
<br />April 9. 1946
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE,STATE
<br />Ntbraska
<br />9d. STREET AND NUMBER
<br />4255 Michigan Avenue
<br />9b. COUNTY
<br />Hall
<br />ed. COUNTY OF DEATH
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />88803
<br />9g. INSIDE CITY LIMITS
<br />55 YEa O NO
<br />10a. MARITAL STATUS AT:11ME OF DEATH E Married 0 Never Married
<br />© Married, but 'operated 0 Widowed ❑ Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Lest, Suffix)
<br />Emil Obermiller
<br />13. EVER 4N U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes. No, or Unk.) Yes ; 12/28/1985-12/08/1967
<br />15. METHOD OF DISPOSITION
<br />E Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑;Removal 0 Other(Specify)
<br />10b. NAME OF SPOUSE (First, , MIddte, Last, Suffix) If wife, give maiden neer*
<br />Elizabeth Elaine Moffett
<br />12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />Anna Hagmann
<br />14a. INFORMANT -NAME
<br />Elizabeth Elaine Obermiller
<br />18a. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />18b. LICENSE NO.
<br />1495
<br />14b. RELATIONSHIP TO DECEDENT
<br />SDouse
<br />111c. DATE (Mo., Day, Yr.)
<br />August 20, 2019
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<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 />CITY / TOWN
<br />Grand Island
<br />CAISE OF DEATU (See tngtruction;am) examples)
<br />4S. PART I. Enter nest chain of event'. .diseaeas, injuries, or compliations4het directly caused tip death. 00 NOT enter terminal events such as cardiac arrest.
<br />respiratory ayMet, at osntripular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one aum:on a line, Add additions! lines If neceeeary.
<br />IMMEDIATE CAUSE:
<br />a) Heart Failure Exacerbation
<br />IMMEDIATE CAUSE (Phial
<br />disease or condition resulting
<br />in *Mill
<br />*Ifoomlally tm aen4Rlens, R
<br />any. feeding to the cause SWIG
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that InkUted
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Obstructive Pulmonary Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />e)
<br />STATE
<br />Nebraska
<br />ire. zip Coda
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death'
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />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 />Coronary Artery Disease And Heart Reduced Ejection Fraction
<br />20. IF FEMALE:
<br />0 Not pregnant within pier year
<br />0 Pregnant at time of death
<br />0 Nat pregnant, tut pregnant wahin 42 days of death
<br />❑ Not praaaa,u Out Preanant 43 days tel year halo's death
<br />Unknown if poignant WNtb the past yeyr
<br />22s. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />0 YES ❑ NO
<br />21a. MANNER OF DEATH
<br />Ea Natural p Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could riot to determined
<br />22b. TIME OF INJURY
<br />210, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Paseeneer
<br />0 Pedestrian
<br />0 Olher(apacify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ vas ENC
<br />21c. WAS AN AUTOPSY:PERFORMEDF
<br />❑YES ENO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO.
<br />231. DATE OF DEATH (Mo., Day, Yr.)
<br />CITYITOWN
<br />}, 23b. DATE SIGNED (Mo., Day, Yr.)
<br />e 8 3d. To the beat of my knowledge, death occurred at the time, date and place
<br />and due to the cause(') stated. (Signature and Thiel
<br />i
<br />r
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN ❑ YES ii NO
<br />23c. TIME OF DEATH
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr,)
<br />Au • ust 22.2019
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />August 15, 2011/
<br />24b. TIME OF DEATH
<br />02:52 PM
<br />24d. TIME PRONOUNCED DEAD
<br />02:52 PIA
<br />ZIP CODE
<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(*) stated. (Signature and Tit)
<br />Sarah Carstensen, Hal County Attorney
<br />27-. NAME, TITLE AND ADDRESS OF CERTIFIER Moe or Printa (
<br />Sarah Carstensen, Hall County Attorney, 231 S. Locust, Grand Isl= • • aska, 68801
<br />2 e REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 24a Is NO 0 YES ONO
<br />28b. DATE FILED BY REGISTRAR{Mo.. Day, Yr.
<br />August 26, 2019
<br />Amended
<br />9/10/2019
<br />Amended Item 13 No To Yes And Added Dates Of Service
<br />
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