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<br />MEN THIS COPY THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />:BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERWCES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />•11/16/2023
<br />LINCOLN, NEBRASKA
<br />•
<br />304
<br />2023.06:509............SAEAIEN.Amp
<br />ASSISTANTSTATE 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,)*0goamrs-NAME (First, Middle, Last, Suffix)
<br />0•!ItobilirtDeWaykie Dobbins Jr
<br />leo
<br />ihow.„16111418sw.
<br />23 15268
<br />4.OITYAN11:STATEORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cameron, Missouri
<br />SoOLsL 4401217Y. NUMBER
<br />2. SEX
<br />Male
<br />50. AGE Last Birthday
<br />(Yrs.)
<br />75
<br />sb,.:ONDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF OP,AP9M9iO810119,41
<br />Novembet &!.2023
<br />6. DATE OF BIRTH (Mo., Day, yr.)
<br />Ob. FACILITY -NAME (if not Institution, give street and number)
<br />607 Pheasant Place
<br />8c CITY OR TOWkIDE.MATH (Include Zip Code)
<br />1elan4::88801
<br />RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />June 271948
<br />OTHER D Nursing Home/LTC •
<br />Decedent's Home
<br />0 Other (Specify)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />30DTREETAND NUMBER
<br />607110.46.asent Pliee
<br />les. MARITAL STATUSAT TIME OF DEATH jJ Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced D Unknown
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />$g„ IN,SIDECTI'Y Limits
<br />DYES RI NO
<br />10b. NAME OP SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Jennifer Olson
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert DeWavne Dobbins Sr
<br />12 MOTHER'S -NAME (First,
<br />Zona Bills
<br />Middle, Maiden Sumamej:U:::
<br />13 EVER irt:.ixS. Mime FORCES? Give dates of service if Yea.
<br />(Yes, No, or Unk.) Yes 1967-1969
<br />14a. INFORMANT•NAME
<br />Jennifer Dobbins
<br />15. METHOD OF DISPOSITION
<br />:..0 Ouria10 pOnnstion
<br />Ii] cremation OE.,..thment
<br />Removs cipher (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE(51o.„Day,
<br />NoVember8g20a3 •
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All FaithFuneral Home, 2929 S. Locust Street Grand Island, Nebraska fOr
<br />Other
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART 1. 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 additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Mal a)Amyotrophic Lateral Sclerosis
<br />disease Or Condition reeulting
<br />In deatI11, ' .
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />errniieic
<br />BAter tildUNDBRVIINB•EpAUSE
<br />(41144444irinitirttha111litieted
<br />the events resulting in death)
<br />LAST
<br />•
<br />. •
<br />APPROXIMATE INTERVAL
<br />onsetto 4490
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />onset0
<br />onset to death
<br />18, PART II. OTHER SIGNIFICANT CONDMONS-Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Hospice Care and died at home
<br />19. WAS maisci).L EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES g] NO
<br />20. IF FEMALE:
<br />Nei pregnant within Peat via,
<br />Pregnant M*14144*,
<br />sstagnant, but prorg7l
<br />att within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown ff pregnant within the past year
<br />224.DATE ciFINJURY(Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />DYES 0 NO
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Weer/Operator
<br />0 Passenger
<br />D Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />22c. PLACE C)F INJURY -At home, farm, street, factory, office building, construction site, eft, (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22E LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 5, 2023
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 8, 2023
<br />23c. TIME OF DEATH
<br />08:33 AM
<br />:$d.:TAthe Deo an* knowledge, death occurred at the time, date and place • •
<br />tid due tieCituse(s) stated. (Signature and Title) •••
<br />Michael A. Donner, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />yas PROBABLY 0 UNKNOWN
<br />STATE CODE:...:
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e;.poth*:4asis of examination and/or investigation, in my opinion death conk**
<br />She date and place and due to the cause(s) stated. (Signaturdiendlidel
<br />•
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES.
<br />27tlAmaorrimAt.ipApp:stess OF CERTIFIER (Type or Print
<br />44i0haiatNi: 00.0fter, MD, 729 North Custer Avenue, Grand [Stand, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?......:
<br />Not Applicable If 26a is NO 0 VES 0 NO
<br />28a. REGISTRAR'S SIGNATURE
<br />ot-let-111 go/4,0Leirikez,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, YE)
<br />November 9, 2023
<br />0)
<br />
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