|
II
<br />' 111 rf
<br />r
<br />11 rr
<br />ABS ,
<br />.•'If
<br />� 1h l�
<br />.�3, c
<br />"�3� 11,,1c
<br />u1i
<br />rl a4§1ic..
<br />a l
<br />Y
<br />s
<br />a
<br />f
<br />�$ ll 99 ,,!
<br />.RR„i�+,dg ..,
<br />(dI11t�i
<br />4hhh�a
<br />rFPO
<br />wrfePiw/r )Itt41sfr m)1jI//a 4Pali,44rb
<br />bawItlskn_.._._„( IBIh
<br />woe,
<br />STATE
<br />OF NEBRASKA
<br />tirri�2te,ta4WMaaa x �'
<br />r�r4thhWt�� i
<br />y $444t7.plytll9ai
<br />rrl/ill �y111Nt�
<br />il« i t\
<br />�i)1 �Iilie��'ilu((((�fd5
<br />t4+
<br />iii.'311i1mmtoo i*..01.11';illrt(t!1(14h04
<br />4 44 I�iIP
<br />e dtll„i(?�yhfF
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, iT CERTIFIES THE DOCUMENT BELOW Tt
<br />3EA TRUE COPY OF THE ORIGINAL. RECORD ON FILE WITH THE NEBRASKA ! DEPARTMENT OF HEALTH AND
<br />?. HUMAN :SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />bATEC)fi;ISSUANCE.:
<br />11.191,022
<br />LINCOLN,NEBRASKA.
<br />202304871
<br />ICA ,::"t
<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 />DECEDENT'S:NAMS(Fi(st Middle, Last, Suffix)
<br />Robert Dean Real
<br />4,:01TY AND STATE OR'rERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />ood. Rlvery Nebraska
<br />!CIAL SECURITY NUMBER'•
<br />50746-0977
<br />5a,;AGE Last:Birthday:.
<br />(Yrs.)
<br />fib: PACII:ITY^NAME(If l7otliistitution,, give street and number)
<br />Grand Island Regional' Medical Center
<br />8c,:CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Isla id 6$803'
<br />RESIDENCE -STATE
<br />Nebraska,':
<br />STREET AND NUMOEIt;:.-
<br />809 F 9th.:.:::
<br />"MARITAL.STATUS.AT-TIME„OF. DEATH MI Married 0 Never Married
<br />arried, but separatist 0:Wrdowed 0 Divorced 0 Unknown
<br />FATHER S t AME tFitst Middle ` ;Last, Suffix)
<br />eonafd
<br />76„„:„„„,
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH
<br />HOSPITAL 1] Inpatient
<br />0 EPJOu patient
<br />0 DOA
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE'OF DEATH (M'o,,
<br />October 2, 2422.
<br />OTHER 0 Nursing Hone/LTG
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />Facility
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />8d. COUNTY OF DEATH.
<br />Hall
<br />9.e. APT. NO.
<br />9f, ZIP CODE
<br />68883
<br />tib. NAME OF SPOUSE (First,' Middle, Last, SuMix) If wife, give.
<br />Betty A Reimers
<br />12 MOTHER S -NAME (First, Middle,
<br />Barbara J Hyke
<br />9gy3N
<br />I, .4111.4ETS:
<br />.NO
<br />Maiden Sums
<br />EVER iN U SARIv11SD FORCES? :<ive.dates of service if Yes.
<br />(Yee No; or.'tlnit) fes :,:‘:04/.1911•966-99/19/1968
<br />14a. INFORMANT -NAME
<br />Betty A Carlson -Real
<br />14b. RELATiONSHdP'TO DEOECE
<br />.Spouse',
<br />16 METHOD OF DISPOSITION
<br />l2 Burial 0-f Oonati.�ir1.'.
<br />Cremation ti Entoiilbms
<br />Reinpval j
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16b. LICENSE NO.
<br />1191
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION'
<br />Wood, River Cemetery
<br />FUNERAL HOME NAME ANO MAILING ADDRESS (Street, City or Town State):.,,,
<br />sfel Funeral Home 1123: W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions Ahtl examDles)
<br />;a. PART I, Enter the shaig' otreyents- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or. ventriculariibritlation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />Pulseless electrical activity
<br />October 6, 21)22.
<br />•
<br />4Th Zrp.God
<br />68Si11 >`
<br />Sequentially: list conditions, If
<br />any, ;leading to.tlaeTEu$e listed
<br />APPRO
<br />INTERVAL
<br />DUE TO, OR A CONSEQUENCE OF:
<br />b)Pulrnonary embolus
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />Eritg[th,UNDEPLYINGCAt;l56 c)Non small cell lung cancer
<br />Idlstiasti�or ink*. eiiat.iaiONO
<br />the .eventsrestiinng.Indeath)
<br />LAST; .. .
<br />TO, OR AS A CONSEQUENCE OF:
<br />at
<br />18 PART I# OT 4ER S(GNIFICANTT.CONDITIONS-Conditions contributing to fhe loath but notrasurting in the underlying cause given in PART'(:..
<br />Scute gastrointestina) bleeding . peptic ulcer disease, acute blood loss anemia, atrial fibrilllttiorr, coronary artery `disease, diabetes ..'.
<br />.irielirtus typS 2 morbid';. obesity,: hypertension, hyperlipidemia
<br />8 iF.:FEMALE? .
<br />Not pregnant elthin pa . _
<br />nanl at t me 01 dee '
<br />let AregnentR but pregnant tikithin 42 days of death
<br />reg
<br />t%lttt' pregnant, tigt p egnant 43.'tlays to 1 year before death
<br />Unknown i1,pi'egnant w%dtln ate past year
<br />22a .HATE OP INJURY (Mo, Day
<br />22E. INJURY'AT WORK?
<br />NO<:::,::;:.
<br />LOCATION'Qir 144(likY `STREETE,:NUMBER, APT.NO.
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homipide
<br />•
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21,b IF.TRANSPORTATION INJURY
<br />❑ DnvarIOperator
<br />© Passenger
<br />Pedestrian
<br />0 Other (Specify) •
<br />1$ WAS':MEDICAi ;EXAM►NER ? ..
<br />DR'0RONER.1«ONTACTE64:
<br />YES .. NO
<br />•
<br />21d. WERE AUTOPSY PIND)NGS AVAlI ABLE
<br />TOCOMPLETE:CAUSE'OF.SEATH?:'.:.::.
<br />.0)4
<br />0 II
<br />22c PL,ACE:OF INJURY•At home, farm, street, factory, office building, cotistructlon site;:S
<br />22e.:RESCRIBE HOW INJURY OCCURRED
<br />CITWTOWN:;r
<br />z
<br />23a.DATE DEATH (Mor, Day; Yr.)
<br />:: October 2;:2022 ` .
<br />23b DATESiGNED (Mo Day, Yr.) . 23c. TIME OF DEATH
<br />Octtter 4,:2022 10;19 AM
<br />Sad TothS bestottny Itgowledge; death occurred at the time, date and place
<br />and due to the teasels) stated; (Signature and Title)
<br />Jay G AnderSOr4 MD
<br />25. DID TOBACCO USE,CONTRIBUTE TD THE DEATH?
<br />YES 0 NO. O PROBABLY ® UNKNOWN
<br />2T NAMe, ITI,EANt3 4DiRESS OF CERTIFIER (Type or Print
<br />Jay C Anderson,'MD; 729. North Custer Avenue, Grand Island, Nebraska 6880:
<br />ir•
<br />8
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ODE
<br />24b, TIME OF DEATH...
<br />24d- TIME PRONOUNCED DEAD
<br />the basis of examination and/or investigaaon, ln.my opinion heir nth osti
<br />s ama, date and place and due to the cause(s)stated. (Signature enq:¶
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES NO
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS:CONSENTORANTE?
<br />Not Applicable If 28a is NO., .
<br />28b. DATE FILED BY: REGISTRAR
<br />October 12, 2022
<br />YES'
<br />
|