202106571 - Laserfiche WebLink

Browse

4 '-qrlg,rd ^C +t?�@ yep ++k 3K �W,Wig,. A,6ir��tiyaTa56A iiia (148 499 a6Aii, �t �iM�' N } 1 Rasx ai.44yayyAA$tx+a a chill lii5xx, c ts6G4MdOwrt /k� WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 12/18/2020 LINCOLN, NEBRASKA 202106571 SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES C 20 18107 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 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Robert Eugene Walker 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) December 8, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 70 MOS. DAYS HOURS MINS. January 23, 1950 7. SOCIAL SECURITY NUMBER 505-64-0897 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d, STREET AND NUMBER 1603 W. Koenig Street Be. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® Vas 0 NO 10a MARITAL;STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Debra Newcomb 11, FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Sumame), James Walker '< Darleen Munnell 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 10/08/1968-10/03/1972 14a. INFORMANT -NAME Debra Walker 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Burial ❑ conation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo Day, Yr.) December 10, 2020 Cremation ❑Entombment Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b, Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 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, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: INMEDIATECAusEtFIsSI - a) Hypoxic Respiratory Failure disease or condition resulting onset to death Hours In death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)Aspiration Pneumonia any, leading to the cause fisted on fine a. onset to death Days DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C)Subdural Hematoma (disease or wary that Initiated onset to death' Days the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) Falls onset to death Days f$, PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Tongue Cancer 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20.1F FEMALE: 0 Not pregnant within past year Pregnant at time of death 21a. MANNER OF DEATH ❑ Natural 0 Homicide ® Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 0 Not pregnant, but pregnant within 42 days of death9ulcida 0 Not pregnant, but pregnant 43 days to 1 year before death ❑<, Unknown if pregnant within the past year could not be determined ❑ ❑ ❑ PedesMen ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) November 29, 2020 22b. TIME OF INJURY Unknown 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Home 22d. INJURY AT WORK? ❑YEs ®No 22e. DESCRIBE HOW INJURY OCCURRED fell, hit head on bedframe 22f, LOCATION! 1603 OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE W Koenig St, Grand Island Nebraska . 68803 S I 23a. DATE OF DEATH (Mo., Day, Yr.) December 8, 2020 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH i F ,. I kg' z 23b. DATE SIGNED (Mo., Day, Yr.) December 16, 2020 23e. TIME OF DEATH 05:20 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD uO .II- f 29d. To 3M best of my knowledge, death occurred at the time, date and place ane due tette cause(s) stated. (Signature and Title) Zachary W. Meyer, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at '. the time, date and place and due to the causes) stated. (Signature end Title)" 25. D1D TOBACCO; USE CONTRIBUTE TO THE DEATH? ® YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 28a Is NO " ❑ YES ❑ NOI 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Zachary W. Meyer, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 6k/14. .8.41. /cs-e7"2 fes' 28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.) December 16, 2020