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<br />�p')311itlyi STATE OFNEBRASKA_
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<br />WHEN THIS COPY -CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMANSERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFFISSUANCE
<br />7/5!2023
<br />LINCOLN, NEBRASKA
<br />202303682
<br />3Mt a
<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 />1. DECEDENT'S -NAME (First, : Middle, Last, Suffix)
<br />Robert .:Alan Williams
<br />4. C(TY AND STATE OR
<br />•
<br />CERTIFICATE OF DEATH
<br />TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7 $OCtAL SE RIV NUMBER
<br />"506-90-7890
<br />Sb. FACILITY -NAME (Knot Institution, give street and number)
<br />1318,W John St
<br />8e Y OR TC)WN OF DEATH
<br />+"stand Is(a 1d 88881
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />8d,:;STREET AMID NUNRER
<br />1398 W Dolan St
<br />1
<br />elude Zip Code)
<br />Sa,AGE Last Birthday
<br />(Yrs.)
<br />62
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />84. PLACE OF DEATH
<br />HOSPITAL. ['inpatient
<br />ER/Outpadent
<br />❑ DOA
<br />9b. COUNTY
<br />Hall
<br />ITAL;$TATue AT TIME OF DEATH El Married 0 Never Married
<br />Married, but separated ' ❑ Widowed 0 Divorced 0 Unknown
<br />11 FATHER 8 NAME (First, Middle, Last, Suffix)
<br />Rex Wiolams
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />15. METHOD OF DISPOSITION
<br />Butlat ❑ Donation
<br />❑' Cremation ❑ Entombment
<br />(]Remove# ❑ ottier (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 08834
<br />3. DATE OF DEATH :(Mo., /(lay '1i r.)
<br />June 20 2023.
<br />8. DATE OF BIRTH (Mo., Day; Yr.);
<br />September.111 1960.::.
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />1Ob. NAME OF SPOUSE (First, Middle,
<br />Debra Minpus
<br />14a. INFORMANT -NAME
<br />Debra Williams
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />9f. ZIP CODE
<br />68801
<br />Last, Suffix) If wife, give meidei
<br />INSIDE OITY ti(' S
<br />YES ❑;NO
<br />12, MOTHERS -NAME (First, Middle, Malden Surname)
<br />Dorene Gilbert
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Alda Cemetery
<br />17a; FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />dell Faiths; Funeral! Home, 2929 S. Locust Street, Grand Island,Nebraska
<br />CAUSE OF DEATH (See inert(
<br />16b. LICENSE NO.
<br />1495
<br />14b. RELATIONSHIP TODECEDENT.:
<br />Spouse;
<br />16C. DATE (Mt
<br />June 28
<br />CITY / TOWN
<br />Alda
<br />one and examples)
<br />18. PART I, Enter the chain of events..dseasee, Injuries, or complications that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respbatoly arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Unknown Natural Causes
<br />• IM Dut.'#E CAUSE (abet
<br />dlsaaseur t ondk tin re apart :
<br />M deattti
<br />aaquenpaiiy list conditions, If
<br />ay,'lead iO attire cause listed;
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b),
<br />STATE
<br />Nebraska
<br />1Tb Zig Cods <:..
<br />68801.
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EewebaUNDERLVINGOAUSE C!
<br />(dictate. or Injury -tat Netted
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 A.ART (i OTHER SIGNIFICANT CONDITIONS•Conditions contributing to the death hut. nit Yesulting In theunderlying cause given in PART I.
<br />_20 IF FEMALE
<br />Nat prsgrasM wstifn.paat:yar
<br />❑ Pregnsmetteneefdeathj
<br />❑ >Natpregmiet, but p > nt wlttn a2 days Of death
<br />© Not.pregnant, but pregnant 48 rays to1 year before Bath
<br />❑.`:unknown it pregnant wltltn ttt9 past year
<br />32a DATti OPIH )URY (Mt:, Day, Yr.)
<br />g 22d. INJURY AT WORK?
<br />❑ YES :::.❑No.;_
<br />21a. MANNER OF DEATH
<br />Natural ❑ Hon*ide
<br />ElAccident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />24b.IF.TRANSPORTATION INJURY
<br />0 Diever/Operetor
<br />•"0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />onset to death
<br />19. WAS MEDISAL EXAMINER .
<br />OR CORONERCONTACTED?
<br />I YEt3 ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSYFINDINGS Ai/ARABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑.NO
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction site, e3C,:'(3
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f100ATIONQF)NJURY STREET 8, NUMBER, APT.NO.
<br />0
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />a. Utile beat army: knowledge, death occurred at the time, date and place
<br />Xrla due to albeause(s) stated. (Signature and Title)
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES Fi NO ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME, TM AM!) ADDRESS OF CERTIFIER (Type or Print
<br />24a. DATE SIGNED (Mo., I4ay, Yr.)
<br />June 27, 2023
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />June 20, 2023
<br />all7)
<br />24b. TIME OF DEATH
<br />Unknown
<br />24d. TIME PRONOUNCED DEAD
<br />05:1511/414::
<br />T4s On the basis of examination and/or investigation, In my opinion death coaarred at
<br />lifetime, date and place and due to the cause(s) stated. (Signature and Title)
<br />Martin Klein, Hall Deputy County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />26b. WAS CONSENT GRANTED? ,...,..
<br />Not Applicable If 26e is NO 4.l YES
<br />[I
<br />Marti Klein, Hall'DeputyCountyAttorney, 231 S. Locust, Grand Island, Nebraska,` 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) •
<br />July 3, 2023
<br />01
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