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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 AN HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECOR .jj r w7
<br />i] tJ SARAH BOHNENKAMP
<br />DATE OF ISSUANCE 0 2 O 0 elISTANT STATE REGISTRAR
<br />AND HUMAN SERVICES
<br />FEB 3 2020
<br />LINCOLN, NEEM7AOKA
<br />DECEDENTS4AME (Fint, Middle,
<br />Robert Douglas Pape
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Lest, Suffix)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sioux City, Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />503-62-3281
<br />O. FACILITY -NAME (If not Institution, give street and number)
<br />Nebraska Medical Center -University
<br />Se. CM OR TOWN OF DEATH (Include Zip Cods)
<br />Omaha 68198
<br />as. RESIDENCE -STATE
<br />Nebraska
<br />STREET AND NUMBER
<br />2504 Commerce Avenue
<br />Taa AGELial Birthday
<br />(Yrs.)
<br />s0
<br />O. UNDER 1 YEAR
<br />MOS. DAYS
<br />See PLACE OF DEATH
<br />f jOSPtTAL; ® Inpident
<br />ER/OutpstleM
<br />Q DOA
<br />f0. COUNTY
<br />Hall
<br />CITY -.DR TOWN
<br />Grand Island
<br />2. LEX
<br />Male
<br />6e. UNDER 1 DAY
<br />HOURS -MINS.
<br />May 28, 2011
<br />Q11J & 0 Nursing HanM.TC
<br />❑ Decedent's Horne
<br />❑ o310(spy)
<br />Ilid COUNTY OF DEATH
<br />1 Douglas
<br />kd
<br />e.. APT. NO.
<br />N. ZIP CODE
<br />68801
<br />10e. MARITAL STATUS AT TIME OF DEATH 0 Marded 0 Newt M 10b. NAME OF SPOUSE (Rua, Middle, Last Suffix) N wile, give maiden nems.
<br />13 Married, but separated ❑ Widowed ® Divorced 0 Unknown<
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert 0 Pape
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Philomenia 0 Gesiriech
<br />Elmo*. Pawl,
<br />eg. INSIDE CITY LIMITS
<br />fYea _.,.QNo
<br />13. ELVER IN U.S. ARMED FORCES? 0ive dates of service N Yes.
<br />(Yee, No, orUnk.) No
<br />15: METHOD OF DUPOSn1ON
<br />❑nodal ❑Denetloe
<br />Cnelsdoa ❑nMpnboont
<br />14a. INFORMANT -NAME
<br />Kathy Pape
<br />14b. RELATIONSHIP TO DECEDENT
<br />Sister
<br />tq. EMBAL
<br />RE
<br />11%. LICENSE NO.
<br />ek ill
<br />QRsw r ❑ourdetxKNrl hid CEMETERY, CREMATORY OR onset tsaCAT1ow
<br />Heafey-Heafey-Hoffmann-DWorak 8 Cutler Crematory Omaha
<br />IIL FUNERAL HOME NAME AND MAMNG ADDRESS (Street City Or Tomo. Stan)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CITYNOWN
<br />150. DATE (M0., Dry, Yr.)
<br />June 2, 2011
<br />STATE
<br />Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />iLPARTI. EMIihe 222222C.122122 . dlawsu,Wades, or rornplIcadone- that Moody tamed the Amu,. 50 NOT ,autsankW awns such ee cardiac wrest,
<br />'•seannmy omit, r wnaWisrMNlWr, Whoa shooing Ito etiology. Do ND_ABan_YNTE&nor otWo s OOP ens *woos Nsrloon Yee_ mummy.
<br />IMMEDIATE CAUSE
<br />IMMEDIATE CAUSE (Final {�,�
<br />disease reonUon resulting a) e5-1 (Q,''U
<br />M death)
<br />DUE TO, OR AS A C0113EQUI111113130/it
<br />(Primary site presumed Liver)
<br />ssln,wru uo2t temndlNone, I b) Ne -o e,Y\�aCjeity(. 'ltATlrlc7y' - Malignant
<br />enY. ihedktg te tI. moue. a.tw
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Werth* UNDERLYING CAUSE 0)
<br />Miseries or injury that Initialed
<br />Me events resulting M death) DUE TO, OR AS A CONSEQUENCE OR
<br />LAST`
<br />d)
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE RITE/MA
<br />onset to death .. ....
<br />121 <v'S
<br />onsethi th
<br />/5 daA,1S
<br />onset to death
<br />15. PART N. OTHER SIGNIFICANT CONDITIONS -Conditions conbibuttnglo the With but net reauH1na M sen
<br />underlying cause given M PART I.
<br />casette: death
<br />1e. WAS MEDICAL, EXAMINER
<br />OR CORONER CONTACTED/
<br />❑ YES NO
<br />20.1F FEMALE:
<br />[»]tNot pregnant within past year
<br />EPr gr ,Int et Oma of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑o01 pregnant, but pregnant 42 days to 1 year before death
<br />❑Unknown If pregnant within the pit year
<br />220. GATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />)4Natorul q Homicide
<br />❑ Accident 0 Penang Investigation
<br />❑ Suicide [j Could not be isle ndned
<br />220. TIME OF INJURY
<br />215. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Ogler (Specify)
<br />210. WAS AN AUTOPSY PERFORMED?
<br />❑ YES )4040
<br />21d. WERE AUTOPSY Femmes AVAILAaLE:
<br />TO COMPLETE CAUSE OF b€ATN7
<br />❑ YES yNO
<br />220. PLACE OF INJURY -At home, form, abut factory, office building, construction Nle, etc. (Spec,fy)'
<br />22d. INJURY AT WORK?
<br />❑ YES ❑-NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22L UQCAT10N OF INJURY - STREET & NUMBER, APT. NO. C(TYrEOWN
<br />22a. DATE OF DEATH Mo., Day, Yr.)
<br />572'g/.10/)
<br />23o. TIME OP OEM
<br />G2,2` Pm
<br />225. DATE SIGNED (M0. Day. Yr.)
<br />Lr'f3' 2-011
<br />3.3d. To the but of my knowudga, death occurred at the time. date and place
<br />and due to the cause(s) sgfpd. (3 re and Title)
<br />24a. ram; 3:3E2D (Ria, Day, TO
<br />STATE
<br />2Ab. TIME OF MATH
<br />m
<br />IIS
<br />ggrll���
<br />ru A cause(s)24e. On the bails of exan.Non angor MvestlgNbn, In my opinion dee& wosuwed
<br />2 z O at the Em., date end place and due to the cause(s) stated. (Signature and Title)
<br />O.
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />25. DID TOBACCO USE CONTRIBUTE 70 THE DEATH? 2q. 11AS ORGAN ON TISSUE DONATION BEEN CONSIDERED?
<br />D YES '14 NO 0 PROBABLY 0 UNKNOWN ]YES }af 110
<br />2T. NAME. ?RLE AND ADDRESS OP CERTIFIER (PHYSICIAN. PHYSICIAN ASSISTANT. CORONER'S PHYSICIAN OR COUNTY ATTO
<br />�{,r�sfi'na --Eai (-cy MD Q859(o Ncbt-SLY 4<<011 CeTcte ,
<br />2SIG
<br />e. REGISTRAR'S SIGNATUREA-Q_C
<br />'Ad. TIME PRONOUNCED DEAD
<br />215. WAS CONSENT GRANTINY?
<br />Not AppScaMe528e1aNO Q YES ❑NO
<br />RNor PrIM)
<br />(TYPe6 tE 64161/5
<br />215. DATE FILED BY REGISTRAR (Mo, Day. TO
<br />JUN 92011
<br />1
<br />
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