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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 />10/26/2021
<br />LINCOLN, NEBRASKA
<br />202109357
<br />.._...,.�.''` 'lf !fr,...t..fi•.da2
<br />SARAH BOHNENKAMP f
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS NAME (First, Middle, Last, Suffix)
<br />Sidney Robert Moe
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Carthage, South Dakota
<br />7. SOCIAL SECURITY: NU
<br />50446-3866
<br />MISER
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />705 Dean St.
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island $8801
<br />ga. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />705 Dean St.
<br />9b. COUNTY
<br />Hall
<br />81
<br />5b UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 14102
<br />3. DATE OF DEATH (Mo.,:1Day, Yr
<br />October 17,:::2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 27, 1940
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />❑ Hospice Facility.
<br />8g. INS)DS<CITY LlMIT5
<br />❑ YES' ®Nb
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Jeanette Curio
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Gladys Johnson
<br />Robert Moe
<br />13. EVER IN U.S.ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Jeanette Moe
<br />14b. RELATIONSHIP TO DECEDENT'
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />['Burial ❑ Donation
<br />2 Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.) .:
<br />October 19, 2024
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Cameron Cemetery
<br />CITY! TOWN
<br />Wood River
<br />STATE
<br />Nebraska
<br />ha. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />Rosman CAUSE (final a) Lung cancer
<br />dielsse Vt donditi4n rashhirtg
<br />In death)
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />on linea.
<br />Emyr the 41NDER YINO S:AtJSE
<br />(diSadie or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset -to death
<br />Mon tis
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onsef#o death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PARTII. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting. In the underlying cause given In PART I.
<br />Ischemic cardiolnyopathy,'coronary, artery disease, heart failure, copd
<br />19. WAS MEDICAL EXAM)NER
<br />OR CORONERCONTACTED?
<br />❑ YES NO
<br />20. IF FEMALE;
<br />❑ ,t4dt pregnao•within pest pear
<br />❑. Pregnant at time df dedth
<br />❑ :hot pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22a, DATE Of INJURY (MO., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />10
<br />gg
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 17, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 18, 2021
<br />23c. TIME OF DEATH
<br />06:12 PM
<br />22d. Toth beet of my knowledge, death occurred at the time, date and place
<br />end due to tits causes) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />25. DID TOBACCO USE :CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN
<br />A•5
<br />C v
<br />l g
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />Passenger
<br />Pedestrian
<br />❑ Other (Specify)
<br />ome, farm,
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES RI NO
<br />21d. WERE AUTOPSYFINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑: NO,,.
<br />treat, factory, office building, construction site,.:ASPe0441
<br />STATE ZIP
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investiga Ion, in my opinion death occurredat
<br />the time, date and place and due to the cause(s) stated. (Signature and Title) .>.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ❑'NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />October 21, 2021
<br />
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