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<br />, V THIS COPY CARRIES THE RAISED SEAL OF STATE OFNEBRASKAt IT CERTIFIES THE DOCUMENT BELOW TO
<br />A TRUE COPY OF TME ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />IN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />PATE OPISSUANCE
<br />5/30/2023
<br />INCOLN, NEBRASKA
<br />202303672
<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. D1 CEDENTE AM.E, (First, Middle, Last, Suffix)
<br />Robert Curtis Evans
<br />2. SEX
<br />Male
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7• SOCIAL SECi1Rl'I'YNUM:BER''
<br />5€17 6^ 0978
<br />&CAGE Last Birthday.. Sb.'UNDER 1 YEAR
<br />(Yrs )
<br />2
<br />8
<br />8
<br />8b, FACILITY -NAME (if ttot Institution, give street and number)
<br />21.8 Comrnanchei: Avenue
<br />OR TOWN OF, DEATH (Include Zip Code)
<br />Grand Island 66803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />75
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF:DEA Th
<br />HOsprrAL, (,J Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (MOE. Day
<br />May 18, 2023
<br />6. DATE OF BIRTH'(/1o., Day, Yt` )
<br />November 19,1947
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Speciy)
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />•
<br />ospiCeFe ty <:
<br />Sd. STREETANDNUM#ER'::
<br />216 Coinmanctie Avenue
<br />10a. iii)Aitrr'AL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑'Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />Ba. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />90 INSIDE CITY ME
<br />188 YE& ❑ I`10
<br />10bl• NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Ronda Sue Paulman
<br />11 THER8N NE (fiPrst, Middle, Last, Suffix)
<br />Faymond Evans
<br />13. EVER IN U.SS.<Ammo :FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 07/25/1966-04/01/1970
<br />14a. INFORMANT -NAME`
<br />Ronda Sue Evans
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />ENO Rube
<br />14b. RELATIOMBF)IP TO DECEDENT
<br />Spouse
<br />15. METHOD OF OISPOS.ITION
<br />® Burial �] ponat on
<br />o Cremation <;❑ Sntombatent
<br />❑Removal '❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Hillside Cemetery
<br />18b. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Wolbach
<br />16c. DATE (Mo Dsy Yr.)
<br />May 25, 9023
<br />SATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain 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 addhional lines if necessary.
<br />• IMMEDIATE CAUSE:
<br />hM4A IATaCAUSEVan •: ' a) cancer of the colon
<br />disease or condithm resuaing
<br />in death::;;:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />::any,.ieed'm„g to the:calme:iieted
<br />on find
<br />Entertle:UNDERLYIN6:9E.l. SE
<br />(d cease fir inwry flue Initiated
<br />the events resulting in death).
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C),
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />`18.'PARTt OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the Meth but not [esutting M the underlying cause given In PART I.
<br />hepat)e metasleses
<br />1?b ZlpCode;
<br />68801.
<br />APPROXIMATE INTERVAL
<br />amino***
<br />3 Years...:
<br />onset to death
<br />onset
<br />onset to death
<br />19. WAS MEDICAL EXAMINEE.:
<br />OR CORONER.CONTAC ED •
<br />❑ YES ®NO
<br />Gr. IF;FEMALE:
<br />❑ Not pr°gil°at Mdtilrn ),fiat year
<br />Pregnant et time of death
<br />Cl>
<br />Not..gnant but pregnant Within 42 days of death
<br />❑ Not pregnant, but pregnant u days to 1 year before death
<br />U.nknovrn if 1?r6assntwidiM the paet year
<br />TEOP!N./1RY(Mo. Day, Yr.)
<br />1. MANNER OF DEATH
<br />Natural ❑ oomfcide
<br />❑ Accident 0 Pape ding Inveapgatigd
<br />o Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF -TRANSPORTATION INJURY
<br />0rNer/Operetor
<br />Passenger
<br />0 Padestnan
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORM
<br />❑YES ®ice
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />1:1 YES I:1 N° ;:...
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, e
<br />csr�y)<
<br />E
<br />224, INJURY AT WORK?
<br />OYES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCAT)ONOFINJURY-STREET& NUMBER, APT.NO.
<br />__ DATE OF DEATH (Mo., Day, Yr.)
<br />May 18, 2023
<br />23b. DATE SIGNED (Ma., Day, Yr.) 23c. TIME OF DEATH
<br />MAT 23,..N023 09:02 AM
<br />�23d To lite be#t of MXhnowledge, death occurred at the time, date and place
<br />airtltue1aadi I:euse(s) stated. (Signature and Tale)
<br />ary'Settie, MD . .
<br />CITY/TOWN;
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />A•.
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD..
<br />toe. On the hams n
<br />of examination andlor investigation, in my opinioe dea8t recur ed M
<br />the tMna; bate and place and due to the cause(s) stated. (Signature M471010
<br />DIO TOBACCO USE CONTRIBUTE TO THE DEATH? 28e. HAS ORGAN ORrissok, ooNpioN,BEEN CONSIDERED?
<br />YES NO PROBABLY ® UNKNOWN Q YES 14 No,
<br />NAME, Tin[',' NCO ADDRESS OF CERTIFIER (Type or Print
<br />nary Settje; MD, 2116 W Faidley #400, Box 9802, Grand lslard, _ • - l = 68803 '"
<br />EGISTA
<br />S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES E3 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 25, 2023
<br />
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