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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, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />2/26/2019
<br />LINCOLN, NEBRASKA
<br />202000045
<br />6-m"
<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 />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jon Andrew Baker
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 15, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Palmier, Nebraska
<br />5a. AGE Last Birthday'
<br />(Yrs.)
<br />86
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr-)
<br />December 12 1932 ='
<br />7. SOCIAL SECURITY NUMBER
<br />505-36-3701
<br />8b. FACILITY -NAME (I1 not Institution, give street and number)
<br />2320 Riveivis,y Dr.
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2320 Riverview Dr.
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island'
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />VirJeanne Rose Zmek
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Baker
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Gladys Zehr
<br />13. EVER*/ U.S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 02/04/1952-02/04/1956
<br />15. METWODOF DISPOStTtON
<br />Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />❑ RetnoYal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />VirJeanne Rose Baker
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />16b. LICENSE NO.
<br />1495
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., DayYr.)
<br />February 20, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Rose Hill Cemetery Palmer
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />15, PART1. Enter the ;chain of evens --diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventdtt4dr 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) Anemia
<br />disease or condition resulting
<br />ifl deatht
<br />Sequeielelly list 00ttitiom, if
<br />any, wading -to the cause Hated
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Auto Immune Hemolysis
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE1NTERVAL
<br />onset to death
<br />Months
<br />onset tadeath
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />tdlsease or Injury that initiated
<br />the events restating In death)
<br />LAST;:
<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 />COPD, GERD, BPH, Hyperlipidemia, Hypertension, Aortic Aneurysm
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES I11 NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant. within 42 days of death
<br />0
<br />set pregnant, put pregnant 43 days to 1 year before death
<br />D unknown I1 pregnant moo the past year
<br />21a. MANNER OF DEATH
<br />▪ Natural ❑ Homicide
<br />O Accident D Pending Investigation
<br />O Suicide 0 Could not be determined
<br />21b. tF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />D Other (Specify)
<br />21c. WAS AN AUTOPSY) ERFORMED?
<br />❑ YES ENO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />DYES 0 N
<br />22b. TIME OF INJURY
<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 />CITY/TOWN
<br />23a. dral ll: Ol DEAIN (Mo., Day, Yr.)
<br />February 15, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February 18, 2019 05:18 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />anddue to the cause(s) stated. (Signature and Title)
<br />Jay C. Anderson, MD
<br />STATE
<br />244. DATE SIGHED (Mc., Ds::', Yr
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigatbn, 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 TISSUE DONATION BEEN CONSIDERED?
<br />DYES ENO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES
<br />NO
<br />28b. DATE FILED BY REGISTRAR(Mo., Day, Yr.)
<br />February 20, 2019
<br />
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