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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 />8/21/2019
<br />LINCOLN, NEBRASKA
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<br />202001585ASSISTRUSSELL
<br />ANT 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 />Frederick William Fischer
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 12, 2019
<br />4. CITY;AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Langdon, Missouri
<br />7. SOCIAL SECURITY NUMBER
<br />522-34-2009
<br />5a. AGE • Last Birthday
<br />(Yrs-)
<br />89
<br />8b. FACILITY NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />56. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑'<ER/Outpatient
<br />❑'<DOA
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 27, 1930
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />98. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4261 Michigan Ave
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS'
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 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 />Louise Meyer
<br />11. FATHER'S -NAME (First;' Middle, Last, Suffix)
<br />Frederick Fischer
<br />J 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ella Ohrt
<br />l3 EVER IN U.S.ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Louise Fischer
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16e. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />16b. LICENSE NO.
<br />1495
<br />16e. DATE (Mo., Day,Yr.)
<br />August 17, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Phillips Cemetery Phillips
<br />STATE
<br />Nebraska
<br />17a. FLUNERAI. 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 />18. PARTE Eiger the Chain of events- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Chronic Respiratory Failure
<br />disease or condition resulting
<br />*death).
<br />Sequeraialy Ilat conditions, If
<br />any, lading to the anise lietad
<br />on Zine •
<br />Eiger the UNDERLYING CAUSE
<br />(disease **Any that initialed
<br />Me events rearming In death) :.
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Inflammatory Demyelinating Polyneuropathy
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Months
<br />onset to death
<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 />OSA,
<br />20. IF FEMALE:
<br />0 Net pregnant within past year
<br />0 Pregnant at time of death
<br />0 NM pregnant. but pregnant within 42 days a death
<br />0 Not pregnant,. but pregnant 43 days to 1 year before death
<br />❑ unknown it pregnant waht *the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INIURY AT WORK?
<br />YES ❑ No
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NG
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES ❑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 />CITY/TOWN
<br />STATE ZIP CODE
<br />23a. DATEOF DEATH (Mo., Day, Yr.)
<br />August 12, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 13,2019
<br />23c. TIME OF DEATH
<br />05:00 AM
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Thi)
<br />Chad.Vieth, MD
<br />25. DID TOBACCO': USE CONTRIBUTE TO THE DEATH?
<br />0 YES ED NO 0 PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNOED`DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion Wath occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature end 1111e)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES 7
<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 />Chad Vieth:, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />21I11. REGISTRAR'S .SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day,Yr.) I
<br />August 19, 2019
<br />
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