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<br />WHENTHIS 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 />216/2019
<br />LINCOLN, NEBRASKA
<br />RUSSELL FOSLER
<br />Q �y ASSISTANT STATE REGISTRAR
<br />c�
<br />/fir O �+ "� DEPARTMENT OF
<br />HUMAN SERVICES
<br />H
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Robert Leonard Cassell
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />5 7. SOCIAL SECURITY NUMBER
<br />W
<br />o 505-64-1951
<br />`a 8bFACILITY -NAME (If not Institution, give street and number)
<br />2322 N Sheridan Ave
<br />41)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />al Grand Island 68803
<br />9e. RESIDENCE --STATE
<br />Nebraska
<br />6
<br />. AGE - Last Birthday
<br />(Yrs.)
<br />8b. UNDER 1 YEAR
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />Q DOA
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 29, 2019
<br />6. DATE OF BIRTH (Moi Day, W:)
<br />January 19, 1950
<br />OTHER ❑ Nursing Home/LTC
<br />Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />9b. COUNTY
<br />Hall
<br />. " 9d. STREET AND NUMBER
<br />2322 N Sheridan Ave
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Marled, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Leonard Cassell
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN.
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY UNITS
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (Ftret, ,Middle, Last, Suffix) If wife, give maiden name
<br />Chervl Frisby
<br />112. MOTHER'S -NAME (First Middle, Malden Surname)
<br />Constance Rachwalik
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />g (Yes, No, or Unk,) Ni
<br />15. METHOD OF DISPOSITION
<br />g0 Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑Removal ❑ Other l8pecify)
<br />14a. INFORMANT -NAME
<br />Cheryl Cassell
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />February 3, 2019
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />t 17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />CAUSE QF DEATH (See instructions and examples)
<br />12, PART I. Enter the Chain of events- -diseases, injuries, or complications -that directly salad the death. DO NOT enter terminal events such as cardiae anter,
<br />respiratory arrest, or ventn6ular fibriaation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />indeatht
<br />Sequentially list cent tions, if
<br />any, N4dingtethe eause Iieted.
<br />a)
<br />✓ Enter the UNDERLYING CAUSE
<br />t (dtmates% injury that Initiated
<br />the events resulting In death)
<br />a LAST
<br />m
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Pulmonary Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />17b. Zip Code
<br />68803
<br />APPROXIMATE INTERVAL'>
<br />onset to death
<br />6 Hours
<br />onset to deattt
<br />20 Years
<br />onset to death
<br />onset tO death
<br />5 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART 1.
<br />History Of Bacterial Endocarditis
<br />1. 20. IF FEMALE:
<br />0 Not pregnant within past year
<br />t
<br />i ❑ Pregnant at time of death
<br />t1
<br />yq ❑ fie pregnant. Mit pregnsnl within 42 days of death
<br />U ❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown If pregnant within the past year
<br />❑
<br />4-
<br />2 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />1z ❑ YES ❑ NO
<br />en
<br />sr
<br />!V
<br />0
<br />e,
<br />o a:
<br />lo 1
<br />5 z
<br />s o
<br />go z
<br />21s. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Caine not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />mar (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES j,] NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATN9
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office bWlding, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY STREET 8, NUMBER, APT.NO.
<br />23e. DATE OP DEATH (Mo., Day, Yr.)
<br />January 29 2019
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />February 1.2019
<br />23c. TIME OF DEATH
<br />10:20 AM
<br />23d. To the best of my knowledge, death occurred at tha time, date and place
<br />and due to the cause(s) stated. (Signature and TNN)
<br />Gary Sete, MO
<br />5. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />z
<br />STATE ZIP CODE
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, N my opinion des h occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and TNN)
<br />26a. HAS ORGAN OR TISSUE r • ATION BEEN CONSIDERED?
<br />❑ YES 7 NO
<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 />Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island.Islebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (120, Day, Yr.)
<br />February 4, 2019
<br />
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