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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEitAS
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY Fortylm,i
<br />x
<br />i! S, it cER7IFIES
<br />HAND.
<br />DATE OF ISSUANCE
<br />04/09/2012
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN
<br />CERTIFICATE OF DEATH
<br />2021L:1752
<br />tam NT ori{a4Nl+1T * y
<br />220
<br />To be completed/verifled by: FUNERAL DIRECTOR 1
<br />1.DECEDENTS•NAME (First, Middle, Last, Suffix)
<br />John Martin Tobin
<br />2. SEX.. ! ..; c
<br />Male "
<br />;4; EQP TWItAce4 y,Yr.)
<br />`March 27, 2012` ..
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Bhthdsy
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />e. DATE OF BIRTH (Mo., Day, Yr.)
<br />Bancroft, Iowa
<br />(Yrs•)
<br />76
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />January 30, 1936
<br />7. SOCIAL SECURITY NUMBER
<br />483-36-8836
<br />Ba. PLACE OF DEATH
<br />ti4$PQA4 0 Irysadent 9I1:1§6 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (Ir not Institution, give street and number)
<br />Saint Francis Medical Center
<br />® ERIOutpatlerd 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />ec. CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />Grand Island 68803
<br />0d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1122 W. John St.
<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 Dhrorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, last, Suffix) If wile, give maiden nam.
<br />Unda Shriner
<br />11. FATHER'S -NAME (First, Middle, Last, Su1Poc)
<br />John Joseph Tobin
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Jessie Buckles
<br />13. EVER IN U.S. ARMED FORCES? Give dabs of service if Yes.
<br />(Yes, No, or Unk.) Yes 07/01/1953-06/30/1956
<br />14a. INFORMANT -NAME
<br />Linda Tobin
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />18a. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />lab. LICENSE NO.
<br />1411
<br />lac. DATE (Mo., Day, Yr.)
<br />April 2, 2012
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stab)
<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 />To be completed by: CERTIFIER 1
<br />11. PART 1. Enter the R'lal9 at events -diseases, Injuries, or compfpeons4hat ditedly caused the death. DO NOT entertemdnat events such as oaNrec arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on ■ line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Penal a) Cardlopulmonary Arrest
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />octet to death
<br />Immediate
<br />In death) DUE TO, OR ASA CONSEQUENCE OF:
<br />®sesenaily get conditions, n b) Diabetes
<br />my. reeding a the cause BMW
<br />" onset to death
<br />Years
<br />on linea' 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 resulting In &'m) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS•CondRMons contributing to the death but not resulting In the underlying cause given In PART'.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YE$ ® NO
<br />20. IF FEMALE:
<br />❑ Not Pregnant within Pat yew
<br />o Pregnant at time of dote
<br />21a. MANNER OF DEATH
<br />® Natural 0 Hondc de
<br />Accident 0 Pending investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ®No
<br />❑ Net ptegnanl, but pregnant within 42 days of death
<br />El Not pregnant, but pregnant a, days to 1 year before dam
<br />o Unknown N pregnant within me past year
<br />0
<br />Suicide El not a aMemwnw
<br />❑ ❑
<br />0 n
<br />0 Other (SWAM
<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 horse, faint, sheet, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />;;
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />S
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />April 3, 2012
<br />24b. TIME OF DEATH
<br />08:46 PM
<br />J
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />IL
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />March 27, 2012
<br />24d. TIME PRONOUNCED DEAD
<br />08:46 PM
<br />. To the best of my knowledge. death °cc urred at the time, date and prem
<br />T
<br />MIM)
<br />i�x
<br />2 S
<br />tae. On are bad 01 saanWrUon andlor investigation. In my opinion dell!' occurred at
<br />dare due to Me Tare)
<br />E and due a tet muse(s) stated. (Signature and
<br />E
<br />nae and
<br />the One. and place and ousels) stated. (sphr
<br />Barbara Dunn, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE
<br />0 YES
<br />DONATION BEEN CONSIDERED? deb. WAS CONSENT GRANTED?
<br />®NO ``Not Applicable if2Se Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,
<br />Barbara Dunn, Hall Deputy County Attomey, 231
<br />ASSISTANT, CORONER'S PHYSICIAN OR COUNTY eTORNEY) (Type or Print)
<br />S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE'
<br />/C
<br />��O
<br />25b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 5, 2012
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