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<br />WHEN THIS �' CO•PY . CARRIES THE RAISED SEAL OFTHE STATE' OF NEBRASKA,.::. IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY CF THE ORIGINAL .RECORD" .
<br />.
<br />ON FILE WITH `.THE : NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, 'VITAL':.
<br />RECORDS OFFICE; WHICH IS THE LEGAL DEPOSITORY;FOR VITAL RECORPS
<br />DATEOF1SSUANCE •
<br />• 6/9/2021 •
<br />• • LLNCOLN, NEBRASKA
<br />•
<br />LSI
<br />O
<br />g
<br />DECEDENT'$ NAMEFirst, : Middle, Last, Suffix)
<br />Robert `:Edwin Rasher
<br />202301936
<br />94 x:...I&9 , a.
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH.
<br />AND HUMAN SERVICES:
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF.. DEATH
<br />4:: CITY AND: STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Belvidere,. Nebraska
<br />7 SOciAL SECURITY NUMBER
<br />508-30-6353
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />91
<br />8b: FACILITY-NAME'(If not Institution, give street and number)
<br />EdgeWQod Vista Grand island
<br />8c,:PITY OR TOWN OF DEATH.(Include Zip Code)
<br />Grand Island 88803
<br />9' 9a. RESIDENCE -STATE'
<br />Nebraska:
<br />d
<br />94. STREET AD N
<br />:202ViWiPrk
<br />UMBER:,
<br />9b. COUNTY
<br />Hall
<br />all UNDER 1 YEAR
<br />2. SEX
<br />Male•
<br />6c. UNDER I DAY
<br />0721.9
<br />3. DATE.OF,DEATff (Ma, Day Yr.)
<br />May '25, 2021
<br />6. DATE'OI=:BIRTH(Mo.,
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0Inpatient
<br />0 Eft/Outpatient
<br />DAYS:
<br />a DOA
<br />10a MARITALSTA1jS`AT TIME. OF DEATH ® Married 0 Never Married
<br />0 Married, but separated .0 Widowed 0 Divorced 0 Unknown
<br />11 ATHERSNAME Bret,•Middle,' Last Suffix)
<br />Harrtr E : Rasher;..
<br />13 EVER IN U.S. ARMED FORCES? dive dates of service if Yes.
<br />(Yea,No, or Unk.i N0...
<br />15 :METHOD QF DISPOSITIOPi
<br />B Budal [ Donation•
<br />c
<br />• Cremation E Entornbnient
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />May.12'1:9
<br />OTHER 0 Nursing:Nome/LTC •`
<br />0 Decedent's Home
<br />® Other (Sl?et IfY1ASSI$T D i:VING
<br />Hospice Facility
<br />•
<br />lad. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Erma Jene Schrock
<br />4a
<br />1. INFORMANT41AME
<br />Tanya Rasher -Miller
<br />16a. EMBALMER -SIGNATURE
<br />Chris. McCoy
<br />(Specify):
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />a ] Removal` OOther
<br />Grand Island City Cemetery
<br />17a °FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />4 pfe( Fufieral Horne, 1123 W. 2nd, Grand Island, Nebraska
<br />5,
<br />CAUSE OF DEATH (SI
<br />9f. ZIP CODE
<br />68803
<br />MOTHER`S-NAME (First, Middle;
<br />essie . Clifford
<br />16b. LICENSE NO.
<br />1191
<br />CITY / TOWN
<br />Grand Island
<br />89INSIDECITY:1410 S
<br />give maiden name
<br />Maiden• Sdntaroa)
<br />14b. RELATIONSHIP: TO DECEDENT
<br />:. Daughter
<br />16c. DATE (Me., Day,.Yr,)
<br />June 5,°2021
<br />instruction and examples)
<br />18..PART I. Enter the chefs 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 tines if necessary.
<br />IMMEDIATECAtts5{Flnel a).acute• Hypoxic Respiratory Failure
<br />. orsiesa dreenditionresubin
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list con itions, H b)Aspiration. Pneumonia
<br />any; leading to the cadaetisted
<br />flit line S. ' '
<br />DUE`. TO; OR ASA CONSEQUENCE OF:
<br />Eniitrtrtee UNDEILYINO CAUSE • C) Dysphagia
<br />• p . (disease or injury thatInitiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST.
<br />STATE >_
<br />ebraska.
<br />iTb ZIP:C•
<br />6880
<br />• APPROXIMATE INTERVAL ,
<br />tette death
<br />HOurs•
<br />onset to(death '.
<br />Hours
<br />16 PART IIPART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but
<br />Urinary Retention Alzheimer Dementia , Atrial Fibrillation, GERD,
<br />at r 0 IF FEMALE:::
<br />0: Not Prsanaa9 within pestyear
<br />0. Pf@9nant(4ie of death
<br />O • ;Not pregnan;hmt, butpregnant.wlthin 4Sdeys of death
<br />El Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown (fpregnant.within the past. year
<br />22a, DATE OF •
<br />INJURY (Mo Day, Yr.)
<br />Q
<br />c . 22d. INJURY AT WORK?
<br />21a. MANNER OF DEATH
<br />® Natural Homicide
<br />0 Accident 0 Pending Investigstlon
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />ing in the underlying cause given in PART I.
<br />21 b. IF TRANSPORTATION INJURY
<br />0 atver/Operator
<br />�QPassenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19: WAS MEDICAL EXAMINER • :i;.
<br />OR: CORONER•CONTACTED?
<br />DYES (: NO : .
<br />21c. WAS AN AUTOPSY t*ERFi
<br />0 YES•NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH? •
<br />0 YES
<br />22c PLACE OF INJURY.At home farm, street, factory; office building, construction site,
<br />22e: DESCRIBE HOW INJURY OCCURRED
<br />221' LOCATION OF INJURY - STREET&' NUMBER; APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 25, 2021.
<br />CI /TOWN
<br />23b .PATESIGNED'(Mo;, Day; Yr.) 23c. TIME OF DEATH
<br />V.lay 021 •10:30 PM
<br />Th. the bast of,my knowledge, death occurred at the time, date and place
<br />and duete.tl+e causes) stated. (Signature and Title)
<br />Jay C. Anderson, MD
<br />(specify)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c., PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b'; TIME OF DEATH
<br />24d, TIME PRONOUNCED DEgp
<br />24e, On thelasis of examination and/or Investigation, in my'opinion
<br />:.1he fitite, date and place and due to the cause(s) stated. ($.19rp wt;:
<br />26';DID TOBA CCO< USECONTRIBUTETO THE DEATH?
<br />[] YES ;� NO 'El PROBABLY 0 UNKNOWN
<br />2. NAM$ TITLE AN<i.4),IIRESS OF CERTIFIER (Type or Print
<br />'Jay C Anderson, MD,:729 North Custer Avenue, Grand Island, Nebraska;`68803
<br />28a.. REGISTRAR'S. SIGNATURE :.:
<br />c/4-44,}7
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 1 NO,
<br />Gurrea et .
<br />ride)'
<br />26b. WAS CONSENT GRANTED7,::
<br />Not:Applicable If 28a is N0; OYES ry�*ryi IV
<br />28b. DATE FILED ay. REGISTRAR RAO., pay, Yr.
<br />June 3, 2021
<br />
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