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<br />WHEN ' THS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES NE DOCUMENT BELOW TO BE iA 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 OrNSW NCE
<br />LINCOLN, NEBRASKA
<br />20220624:
<br />RUSSELL FOSLER
<br />12/9/201 9
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTI CA1E OF DEATH'
<br />e_ ii1. DECEDENTS -NAME G °hat, Middle, Last, Suffix)
<br />II Thomas Franck Eisenmenger
<br />I ANA rA TE OR TERRIrogT, OR FOREIGN COUNTRY OF BIRTH
<br />Vermtlhon;; outt(Dakota
<br />7. SOCIAL SECURITY NUMBER
<br />.503-58-9707..
<br />aROE Last Esilsilay.: Sti.. UNDER 1 YEAR
<br />(Yrs) MOS. ::DAYS
<br />70
<br />le,
<br />6c. UNUER I DAY
<br />RS
<br />FACRLLTY NAME DInoilnatItudon, give street and number)
<br />3016: deans Driwa
<br />8c. CITY OR MWN OF DEATH (include Zip
<br />GrandWend .6.8803
<br />nestoENCE TAT* : �:
<br />Sd. STREET AND 'NUMBER
<br />3016 Orleans Drive
<br />NTY
<br />Hall
<br />D;ATEOP DEATH (Mo., Day, Yr,}
<br />sr 30,
<br />mowsemi
<br />1
<br />Sa. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing HomSLLTC
<br />ERlOttlpstient ® Decedent's Home
<br />DOA ❑ Other (Specify)
<br />a n aloeTt1NN.
<br />Grend (desert
<br />Sd. COUNTY OF
<br />Hali
<br />lOS. MARITAL STATUS AT:TIME OF DEATH ® Married 0 Never Married
<br />'Married, tot separated 0 Widowed ❑Divorced 0 Unknown
<br />11
<br />FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Paul Eisenmenger
<br />la. EVER IN U.S. ARM RCE$7 Give dates of service if Yes.
<br />(Vett N4, cr link,) NO
<br />5.0111111:14:: . OF POSII1ON 16a EMBALMER -SIGNATURE
<br />.❑ Donation
<br />® Cremation 0 Entombment
<br />Removal : ❑ Otii$t(Spndfy
<br />Stacie L Ruiz
<br />1Ob.:NAME OF..SPOUSE (Ffrst,. Middle, Last,
<br />merry Josephine VanOverbeke
<br />I12. MOTHERS NAME (First,
<br />Robin Ballard
<br />Kerniidbeephine Eisenmenger
<br />St. ZIP CODE
<br />68803
<br />RELATIONSHIP;
<br />LICENSE NO.
<br />1495
<br />IC DATE (Mo. ihtl)lq'Yr.I
<br />December 4, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Gibbon
<br />Central Nebraska Cremation Services.
<br />17e ENERAL H(3NIE NAME AND MAILING ADDRESS (Street, City or Town,State!
<br />AH Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />..::.:�CA#,.�_
<br />1tr PARTt Enter dwelled et MOMS- dleaases, Mbytes. or compticationsdrot directly causer£ the dealt MO fa:IT entrietiuminili evbl. such as canrec enas6
<br />mopIrafrotyeure , orvemdcalar ebetreton without showing the etiology. DO NOT ABEREYSATE. Enter only ane Cavae Ca a tin'4.:Add additional taros If neessaery.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE p:inal a) Acute Cardiac Arrest
<br />a
<br />STATE
<br />Olt
<br />ZiE
<br />1
<br />... m disease or condition resulting
<br />$equenUaiAr f*t GM dhlond, if
<br />any ItadInStCMiacaheaaeted
<br />on ane a.
<br />m
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Congestive Heart Failure
<br />DUE TO, OR AS AC
<br />Enter the UNDERLYING CAUSE c)
<br />4gbeasearinttuyhiatInaialad.`:::.
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST:: d)
<br />r APPROAttBA).E
<br />onset todeath
<br />Seconds
<br />UENCE OF:
<br />A' B 1S. PART IL OTHER SIGNIFICANT CONDITIONS
<br />Pneumonis, High Blood:; Pressure
<br />contributing to the death but not resulting in the underlying cause given In PART!.
<br />IF E:EMAi E
<br />aMotPN9nsrit inflan Past year
<br />❑ Prognaat•
<br />*ttimeofdeath
<br />NM p .fd pMItsai wMfin 42 days of death: -
<br />: N.at pregnant; Sts pregnant #3 days to I year before death
<br />❑ NnkntwMn If pi•.sgnanrwittn ttw past year
<br />tg 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural • 0 liemicide
<br />•
<br />0 Accident 0 Pending Investigation
<br />❑ suicide ❑ Could nit be determined
<br />22h, TIME OF INJURY
<br />JURY.ATW.. RIf?"< :'; 22e. DESCRIBE
<br />rb,:TF TiiANSPORTATION INJ
<br />W DrIverlOperator
<br />o Passenger
<br />❑ P
<br />❑ Othe:IBPecdy)
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office
<br />S. WAS MEDICAL EXAMINER
<br />OR CORONER
<br />c WAS AN.AUTiiPSYF!$
<br />0Yip WINO
<br />2Id: WERE AUTOPSY FINDINGS AVA IASL$
<br />TO COMPLETE CAUSED? DEA'h17_..
<br />El YES ❑
<br />consUvcilal site,
<br />'' 22f. LOCATION OF INJURY STREET & NUMBER,
<br />•NO.
<br />23*. DATE OF DEATH (Mo., Dal% Yr.)
<br />CITY/TOWN
<br />23b. DATE !BONED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />STATE
<br />.. 24a. DATE SIGNED (Mo, !Fay, Yr.)
<br />CieceMber 4, 2019
<br />3d. To the bat of my knowledge, death occurred at tixe
<br />einem caueepi state* (Signature esad Title)
<br />e, date and place
<br />. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. Pay)NNOUR D
<br />x&2.4!, M
<br />24e. On the basis of examination and/or Investigation, iitmy venae death
<br />the time, date and place and due to the cattlie2MitataAa$Mitstun end This)
<br />t erine;J. Doering, Deputy County' CUTIt3y
<br />ITG RANTS
<br />November 30. 2019
<br />26. DiBA= USE CONTRIBUTE TO THE i)EATH? 26a. HAS ORGAN:; DR TISSUED • NATION BEEN CONSIDERED?
<br />0 YES ❑ NO 0 PROBABLY ® UNKNOWN ❑ YES 1 NO Not
<br />27. NAME, TiTLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kati:. nt? Doosin51, Deputy County Attorney, 231 South Locust, Grand island, Nebraska, 68801
<br />28a. ReoisteAi'$ SIGNATURE , ip�'Sn ,. 2Mb. DATE FEED IMY $TRAR{ , D$ 4
<br />, 2019
<br />26a to NO U YE
<br />
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