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<br />DOUGLAS COUNTY
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<br />WHEN THIS! DOPY CARRIES THE RAISED SEAL OF DOUGLAS CQUNTY NEBRASKA, IT CERTIFIES THE
<br />' DOCUMENTBELOW TO BEA TRUE COPY OF THE ORIGINAL RECORD ONFILE WITH THE DOUGLAS COUNTY
<br />HEALTH DEPARTMENT, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />A5iBFtASKA
<br />1e
<br />v
<br />1. DECEDENTS -NAME (First, M
<br />Robert Lee Shuman.
<br />+L CITY. AND STALE OIC
<br />'RlTORY;
<br />202206567
<br />AD/ POUR
<br />HEALTH DIRECTOR
<br />DOUGLAS COUNTY HEALTH
<br />DEPARTMENT
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH SERVICES
<br />CERTIFICATE OF DEATH
<br />Last, Suffix)
<br />FORE
<br />COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />1. SOCIAL SECURITY NUMBER
<br />50854-3950:
<br />8a AGE - Last
<br />(Yrs.)
<br />8b FACILITY -NAME (if not Institution, give street and number)
<br />Nebraska Medicine.
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha. 68198
<br />9a RESIDENCE -STATE
<br />Nebra$ke
<br />9d. STREET AND NUMBER
<br />245 South Kimball Avenue
<br />9b. COUNTY
<br />Hall
<br />Etday
<br />Re. UNDER"1: YEAR
<br />MOS :.DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL R] Inpatient
<br />•Q ER✓Outpatient
<br />❑DOA
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS MINS.
<br />3. DATE OF DEATH
<br />July 27,.2018
<br />Mo., Day, Ycj
<br />8. DATE OF IIIIRTH{Mo , D yrrW) '„::
<br />February 27 f : 7
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (SWIM
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />90. CITY OR TOWN
<br />Grand Island'
<br />ie. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LI11ITa
<br />© YES ❑ NO
<br />1rfa. MArt1TAL STATUSAT TIME OF DEATH 4r,r Married ❑ Never Married
<br />1larretll but$eparatetl ;❑ Wtdowea
<br />Divorced 0 Unknown•
<br />tab, NAME OF SPOUSE#FIn
<br />.:Ellen:K .: Golus
<br />Middle, Last, Suffix) if wife, give maiden nam8
<br />11. FATHER'S -NAME (Mt, Middle,' Lest, Suffix)
<br />Richard Shuman
<br />f12. MOTHER'S -NAME (First, Middle,
<br />Clara Guzinski
<br />Maiden Surname)
<br />8
<br />43::EVERlN U.SARMED;FQRCES? Give cues of service if Yes.
<br />(Yes', No, or Iln[t) Yes :08/15/1966-08/14/1972
<br />18. ma'rece 0€DIBPOsrenti
<br />❑ Burial 0 Daimon
<br />® Cremation 0 Entombment
<br />[:Removal ❑e'3Spey)
<br />14a. INFORMANT -NAME
<br />Ellen K Shuman
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />90. LICENSE NO.
<br />14b. RELA
<br />Wife
<br />ISHP TODECEDENT
<br />lex. DATE (Mb Day, itr.)
<br />August 1, 2018
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION„
<br />Cutler-O'Neill-Meyer-Woodrinp Crematory'"
<br />CITY 1 TOWN
<br />Council Bluffs
<br />17a FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State).:'
<br />Apfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />CAUSE OF DEATH (See ipstrtictil? Is„aryd exampled
<br />Id.PART :i Enter th4dneinet04MM--diseases,injuries, or compncatlonsihatdirectly caused ihedeath poNO *nt*tnnjtu)eoimutsuch ascardlacarrest,
<br />tespJratoty srr.1t or viefltidylar Rbrilaeon without showing the swims DO NOT ABBREVIATE Enter only::aa5 cause en a line. Add addRionai liras a nacsgery.
<br />IMMEDIATE CAUSEd
<br />IMMEDIATE CAUSE (Final ... a) Ventricular Tachycardia
<br />disease or condition resulting
<br />inmate) DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentellyttstcondaionslr b) Heart Failure
<br />:sen,tiaomnglaaamuss asted.:'�on linea
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Ischemic Cardiomyopathy
<br />rttlsease er* irT that Inittited
<br />the events rest ing.In death)
<br />LAe7
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />ti)
<br />STATE
<br />17b:ZtCode
<br />68801
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS.Conditions contributing to the death but not resulting in the underlying cause given In PART L
<br />Gorona(yArteery.Disease, Peripheral Arterial Disease, Diabetes, Cigarettes:: Use
<br />2D IF:FEMALE
<br />0 Not pr+linent ithin part year
<br />0 Pregnant at time of death
<br />Q Nalpre(piastraytpra9oeM pethin#days 4f+
<br />'� NCt Programa elle pgyanait 4* days *0 t year!
<br />0 Olt knnem a pretlnem talon the past Yearr
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. I)JURY.AT WORK?
<br />.Q YES ❑ iao
<br />.............. ........ .........
<br />............. ...... .........
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />Q
<br />Sulaide Cook! 401 be detentheed
<br />22b. TIME OF INJURY
<br />21b,9€ TRANSPORTATION INJURY
<br />❑ Drtvar/Operator
<br />0 Passenger
<br />❑ Psdeatrlsn
<br />Q;xher (SPectIV)
<br />APPRO)t#IG)ATESNTERifAL
<br />ori to dealt;''
<br />ensettoeeen: i.
<br />2 Months.... ;r
<br />onset to death
<br />2 Months
<br />onedttodtIlf
<br />19. WAS MEDICAL EXAMINER
<br />OR COR0NERcc*TACTERT..
<br />21c. WAS AN AUTOPSY PERFORMED? •
<br />❑ YES ®NO.
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, canstructf
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATIONOF INJURY STREET & NUMBER, APT.NO.
<br />233. DATE OFt'TH (Mo., Day, Yr.)
<br />July 27, 2018
<br />CITY/TOWN
<br />2312 DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />August 28, ?018 08:13 PM
<br />23d. To the best of my knowledge, death occurred at the Gm, data and place
<br />and due to the causes) stated. (Signature and Tens)
<br />•tthn Urn, M(
<br />2S DiQ>TOaACGOVSEfCQ11' UTE TO` THE DEATH?
<br />® TES ( NO [] PROBABLY .❑ UNKNOWN
<br />eIs etc {Specify)
<br />STATE ZIP CODE
<br />24as DATE SIGNED (Mo., Day, Yr.)
<br />24d. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b, TIME OF DEATH? :,
<br />24d. 11319 PRONOUttCED'0
<br />24e. On the basis of examinatlon and/or investigation, In my opinion death occurred at
<br />..... the time, date and place and due to the cause(*) stated. ($tgnatute and Tate)..
<br />R
<br />28a. HAS ORGAN OR A'11i)N;iq
<br />❑ YES ENO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)•
<br />JohrlUm, .M;P, 982.3.15 Nebraska Medical Center, Omaha,:Nebra
<br />hi CONSIDERED?
<br />28b. WAS CONSENT
<br />Not Applicable If 28a *NO •
<br />28b. DATE FILED BY REGISTRAR {IB340.ay Yr)
<br />August 29, 2018
<br />
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