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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUM
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ,0
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL'.
<br />DATE OF ISSUANCE
<br />03/26/2010
<br />LINCOLN, NEBRASKA
<br />202103421
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC,gS
<br />CERTIFICATE OF DEATH
<br />To be completedNerifled by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENT'S -NAME (First. Middle, Last, Suffix)
<br />Edward Eugene Obermiller
<br />2. SEX s ' 1
<br />Male
<br />rIC'rj � P t1. �8 r,
<br />` Nkhdl r . _ u
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />8b. UNDER 1 YEAR
<br />tic. UNDER 1 DAY
<br />6. DATE OF *BIN (MO., Day, Yr.)
<br />Dannebrog, Nebraska
<br />(Yrad
<br />72
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />November 4, 1937
<br />7. SOCIAL SECURITY NUMBER
<br />505-48-6013
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient QIHEE ® Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (N not Institution, give street and number)
<br />Tiffany Square Care Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA ❑ Otter (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />913. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />714 W 6th
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 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
<br />Donna
<br />SPOUSE (Fist, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, toddle, Last, Suffix)
<br />Edward Obermiller
<br />12. MOTHER'S -NAME (First, Meddle, Malden Surname)
<br />Dolores Buresch
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 08/16/1961-08/15/1963
<br />14a. INFORMANT -NAME
<br />Donna Obermiller
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Timeree Andreasen
<br />1613. LICENSE NO.
<br />1390
<br />16c. DATE (Mo., Day, Yr.)
<br />March 22, 2010
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑other (speelfy)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Kelso Cemetery Farwell Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Jacobsen -Greenway Funeral Home, 411 0 Street, PO Box 112, St. Paul, Nebraska
<br />17b. Zip Code
<br />68873
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER I
<br />111. PART 1. Enter the Maio of events. eiwaaes, injuries, or oompaatlonsdhat directly awed the death. DO NOT enter tsnnInal events such w cardiac wrest.
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addaonal lines H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Non ST Elevated Myocardial Infarction
<br />disease or condition resulting
<br />onset to death
<br />1 Week
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, It b)
<br />any, leading to the cause listed
<br />onset to death
<br />01111115 a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that Initiated
<br />onset to death
<br />the events reaultlng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS•Condtllons contributing to the death but not resulting In the underlying cause given In PART I.
<br />Pulmonary Fibrosis
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at dm* of death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending bweaegauon
<br />2113.1F TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑YES El NO
<br />0 Not pregnant, but pregnant within 42 days of death❑
<br />❑ Net pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown it pregnant within the past year
<br />❑suicide ❑ Could not w determined❑
<br />Pedewrian
<br />Other (epeefyj
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />0 YES 0 NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />B IMarch
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />19,2010
<br />S
<br />24a. DATE SIGNED (Mo., Day, Yr.) '
<br />2413. TIME OF DEATH
<br />e z
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 22, 2010
<br />23c. TIME OF DEATH
<br />02:45 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />0 . To th best of my knowledge, death ocenrrid ed at the time. date d p
<br />2 and due to the ause(s) shed. (Signature and Tette)
<br />le
<br />1 Travis S. Hageman, MD
<br />E
<br />0
<br />at. On the baseaaminatlon armor krwstgstM lon, my opinion death ooeswed et
<br />h of the tlnw date arra plea and rive to the caws*, stated (Signature and TlW)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE
<br />0 YES
<br />DONATION BEEN CONSIDERED?
<br />® NO
<br />2613. WAS CONSENT GRANTED?
<br />Not Applicable N 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A'TORNEY)
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />(Type or PAnt)
<br />•
<br />28a. REGISTRAR'S SIGNATURE - /7
<br />SIO
<br />2813. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />March 26, 2010
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