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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 />12/18/2020
<br />LINCOLN, NEBRASKA
<br />202106571
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />C
<br />20 18107
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are flied with the county court In the county where the decedent resided at the time of death. 1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Robert Eugene Walker
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 8, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />70
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />January 23, 1950
<br />7. SOCIAL SECURITY NUMBER
<br />505-64-0897
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (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 />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d, STREET AND NUMBER
<br />1603 W. Koenig Street
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® Vas 0 NO
<br />10a MARITAL;STATUS AT TIME OF DEATH ® Married ❑ 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 />Debra Newcomb
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Sumame),
<br />James Walker '< Darleen Munnell
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 10/08/1968-10/03/1972
<br />14a. INFORMANT -NAME
<br />Debra Walker
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ conation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo Day, Yr.)
<br />December 10, 2020
<br />Cremation ❑Entombment
<br />Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<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 />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />111. PART I. Enter the chain of events- diseases, injuries, or complicetionsahat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />INMEDIATECAusEtFIsSI - a) Hypoxic Respiratory Failure
<br />disease or condition resulting
<br />onset to death
<br />Hours
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)Aspiration Pneumonia
<br />any, leading to the cause fisted
<br />on fine a.
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)Subdural Hematoma
<br />(disease or wary that Initiated
<br />onset to death'
<br />Days
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d) Falls
<br />onset to death
<br />Days
<br />f$, PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Tongue Cancer
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20.1F FEMALE:
<br />0 Not pregnant within past year
<br />Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />❑ Natural 0 Homicide
<br />® Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />0 Not pregnant, but pregnant within 42 days of death9ulcida
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑<, Unknown if pregnant within the past year
<br />could not be determined
<br />❑ ❑
<br />❑ PedesMen
<br />❑ Other (Specify)
<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 />November 29, 2020
<br />22b. TIME OF INJURY
<br />Unknown
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />Home
<br />22d. INJURY AT WORK?
<br />❑YEs ®No
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />fell, hit head on bedframe
<br />22f, LOCATION!
<br />1603
<br />OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />W Koenig St, Grand Island Nebraska . 68803
<br />S I
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 8, 2020
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />i F ,.
<br />I kg' z
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 16, 2020
<br />23e. TIME OF DEATH
<br />05:20 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />uO
<br />.II-
<br />f
<br />29d. To 3M best of my knowledge, death occurred at the time, date and place
<br />ane due tette cause(s) stated. (Signature and Title)
<br />Zachary W. Meyer, MD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />'. the time, date and place and due to the causes) stated. (Signature end Title)"
<br />25. D1D TOBACCO; USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO " ❑ YES ❑ NOI
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Zachary W. Meyer, MD, 2116 W Faidley #400,
<br />Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />6k/14. .8.41. /cs-e7"2 fes'
<br />28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.)
<br />December 16, 2020
<br />
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