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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 />9/4/2020
<br />LINCOLN, NEBRASKA
<br />202204314
<br />'ctM .150i .lt.xtlk: L.I
<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 />CERTIFICATE OF DEATH
<br />1, DEDr�ENT S tti4ME.. {F(iat Middle, Last, Suffix)
<br />Robert Francis Fry
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lincoln, Nelrasl:e
<br />SOCIASECURI
<br />LTY NUM$ER
<br />507=74.6871:
<br />8b. FACILITY -NAME (if not institution, give street and number)
<br />CHI Health St. Francis
<br />8c CITY 08 TQWN OP DEATH (Include Zip Code)
<br />Grand Isi&nut 68803'
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />Id. STREET AND NUMBER
<br />35$5 N Hwy 281
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />66
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male ;
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />Ht)$L ©Inpatient OTHER 0 Nurs
<br />gg ER/Outpatient ❑ Dededent's Ho
<br />0 DOA ❑ Other (Specify)
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEAINtMc
<br />August 4, 2020
<br />DA
<br />,;1Y4:
<br />OF BIRT+I (Mo.,
<br />r2
<br />9b. COUNTY
<br />Hall
<br />MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />g0 Married, but separated ❑ Widowed 0 Divorced ❑ Unknown
<br />11. FATHER'S -NAME (Flint, Middle, Last, Suffix)
<br />Francis Marion Fry.
<br />13. EVER IN U.8.1IRMED FORCE$? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />0
<br />15. METHOD OF DISPOSITION
<br />g ❑ Burial .gliZIC,OMf0
<br />Cremation J Entombment
<br />o❑ Removal ❑ Other (Specify)
<br />!e1
<br />8
<br />0
<br />G
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />ire. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />....................
<br />9LYE:G#® IDS:
<br />.
<br />10a.
<br />fob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden narrfe
<br />Michelle Newman
<br />12. MOTHER'S.NAME (First, Middle, Maiden Surname
<br />Letha Jane Leeper
<br />14a. INFORMANT -NAME
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />Michelle Fry
<br />16b. UCENSE NO.
<br />14b. RELATIONSHIP TO
<br />Spouse
<br />16c. DATE(Mo. Day Yr.)
<br />August 7, 2020
<br />CEDENT'
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION I'
<br />Central Nebraska Cremation Services
<br />CAUSE QF DEATH See instructIOnS and examples)
<br />17f3 Zi c.
<br />`'
<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 />68801
<br />18. PART I. Enter the chain of events. -diseases, Injuries, or complicetions4hat 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 Inc.7Add additions) lines if necessary.
<br />IMMEDIATE CAUSE:
<br />tMMEDi. A'I"P, AUS8 (Final
<br />disesae'or uondsIee reSahing :>
<br />In'deetlN
<br />Sequentiallylist conditions, if
<br />any, leading to thereuse Steed
<br />mn urea
<br />a) Myocardial Infarction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Ventricular Fibrillation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Entar tits UNDERU.y1N0 CAUSE ' c)
<br />(dtsease or injury:thin InitMMletl
<br />are events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART41. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In lbs underlying cause given In PART I.
<br />19. WAS MEDICAL:EXAMINER
<br />OR CORONER CONTACTED?
<br />1 YES ❑ NO
<br />20. IF FEMALE:
<br />0 N.otpregnawwki,inpastyear
<br />[3 -Pregnant at lane oP death
<br />❑ Not 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 IMO Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES .❑NO
<br />21a. MANNER OF DEATH
<br />Natural ❑ liomictde
<br />❑ Accident : ❑ Pendin9 Investrgatlaft
<br />Suicide 0 Could not be determined.
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Q. Passenger
<br />Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑
<br />YES �{ ilti0
<br />21d. WERE AUTOPSY'fl(+Ii3.0F DEATH? ABU
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑.NO.
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CATION OP; INJURY::; ;STREET & NUMBER, APT.NO.
<br />23a. DATE OFDEATH (Mo., Day, Yr.)
<br />CITY/T
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />ad. To me best I i thIrSirowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Tithe)
<br />25. DID .;TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />26a. HAS ORGAN OR TISSUE
<br />0 YES
<br />0YES ®NQ ❑ PROBABLY ❑ UNKNOWN
<br />2T. NAM ErITTLBANDADORESS OF CERTIFIER (Type or Print
<br />Benjamin W Shanahan, Deputy County Attomey, 231 South Locust St,
<br />28a. REGISTRAR'S SIGNATURE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />August 28, 2020
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />AuQt)st 4, 2020
<br />QODE
<br />24b. TIME OF DEATH
<br />11:16AM,.
<br />24d. TIME PRONOUNCED DEAD
<br />11:16AM
<br />349. Ott the bask of examination andlor investigation, hi my epinlen ehsedt4Sieiiedid
<br />tha:dm*,:date and place and due to are cause(s) stated. (Signature ant} a)
<br />Benjamin W Shanahan, Deputy County Attorney
<br />DONATION. BEEN CONSIDERED?
<br />NO
<br />26b. WAS CONSENT GRANTED? ..
<br />Not Applicable if 26a is NO ❑ YES . ;d NO
<br />Grand 1st
<br />nd, Nebraska, 68803
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 31, 2020
<br />
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