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STATE OF NEBRASKA
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<br />:WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />EE A TRUE COPYOF THE ORIGINAL RECORD ON FILE VVITit TIE NEBRASKA DEPARTMENT OIF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />21512024
<br />LINCOLN, NEBRASKA
<br />4
<br />202400902
<br />01544/41,
<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 />t beceperm NAME (First, Middle, Last, Suffix)
<br />RobertL.ee Loewenstein Jr
<br />4 CITYANDATATE:ON TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney,: Nebraska
<br />7 t .ICtAL SECURI`CY NUMBER
<br />S064O46554
<br />2. SEX
<br />Male
<br />ea. AGE - La
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />8c CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />a. RESIDENCE -STATE
<br />Nebraska
<br />w
<br />1e. METH00 OF DISPQSITfQN
<br />d Burial Q DanStion
<br />l Cretnatiotf ❑ Entarribment
<br />Removat ❑Other (Specify)
<br />'MEET AND NUMBER
<br />103 E Sunset Avenue
<br />9b. COUNTY
<br />Hall
<br />irthday
<br />Sb::UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PEACE OF DEATH
<br />HOSPITAL 1, Inpatient
<br />❑ ER/Ou patient
<br />0 DOA
<br />Da MARITALSTATUSATTIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />14 FATERS=#NAME (Flt'st, Middle, Last, Suffix)
<br />Robert Lee Loewenstein Sr
<br />13, EVER IN U.S. ARMED' FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />1. DATE OF DEATH (Mo, atw.
<br />January =3#,3,: 2024
<br />OTHER 0 Nursing Home/LTC'
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />pias Faculty
<br />9f. ZIP CODE
<br />68801
<br />9q IN$1D16CIT'ILIMITS
<br />YES ❑ : NO
<br />lab. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden MVO*
<br />Cindy Lee Edwards
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Beverly Ann Johnson
<br />14a. INFORMANT -NAME
<br />Cindy Lee Loewenstein
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />led. CEMETERY, CREMATORY OR OTTER LOCATION
<br />Central Nebraska Cremation Services
<br />7a,FUNERAL ;HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral 'Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions: and examples)
<br />la. 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. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />a
<br />DIATE CAtiSE (pinaF ..::.
<br />disease or aondltfon reauklpy,`3.
<br />deathi
<br />Sequentially Het:conditions,: if
<br />any; leading to the cause pitted
<br />an lilts a
<br />IMMEDIATE CAUSE:
<br />a)failure to thrive, anorexia, malnutrition
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)secondary to ileus
<br />14b. RELATIONSHIP TO DECEDENT:[
<br />Spouse
<br />16c. DATE (Mo., Day, Yr)
<br />Februar+ t O24.
<br />#TATE
<br />Nebraska
<br />6880 i
<br />APPROXIMATE INTERVAL
<br />t'IS death'
<br />onest to death
<br />2 Weeks
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Eniertta UNOERLYIN4 CAUSE D)
<br />(drsease or )njary mat lnidefad
<br />titer events resulting In
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PARTa ETHER SIGNIFICANT CONDITIONS -Conditions contributing tothe death but notresuitingln the underlying cause given in PART 1.
<br />urinary traGt'Infecbls/1•
<br />i6:'• IF FEMALE..
<br />D
<br />Not prel nr nt widths Imst;year
<br />❑` Pregnwlt,f 0me of dataTl
<br />NdFttnegnaf t, twt'pregnard wll
<br />❑. Not pregnetd, but pregnant 43..
<br />Unknownitpregnant rdtltM the past year
<br />In. 42. days of death.
<br />days to 1 year before death
<br />22A. DA
<br />,JURY (Mo Day, Yr.)
<br />INJURY AT WORK?
<br />YES ❑ NO
<br />rs'
<br />21a. MANNEROF DEATH
<br />® Natural ❑ Homidlde
<br />0 Accident ❑ Pending Investigdran
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Driyar/Operator
<br />❑ Passenger
<br />❑ pedestrian
<br />❑ Other (Specify)
<br />22c. ACE OF INJURY At home;
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 30, 2024
<br />Ci /TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 3l. 2024
<br />'23d
<br />:am blest of rtly knowledge, death occurred at thetime, date and place
<br />€ hrid dutlefbe:irauae(s) stated.,(Signeture and Title)
<br />Devin Scott, APRN
<br />23c. TIME OF DEATH
<br />08:00 AM
<br />25.'DID TOBACCO t)SE,CONTRI@UTE TO THE DEATH?
<br />0 YES ®NO t -t PROBABLY 0 UNKNOWN
<br />27 NAMg, TITIN AND ADDRESS OF CERTIFIER (Type or Print
<br />t?evin SCOtt, APRN, 3533 Prairieview St, Grand Island, Nebraska, 68803
<br />onset to
<br />19. WAS MEDIFiAL EXAMINER
<br />OR CORINER CpNTACTE07
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES 51.NO
<br />21d. WERE ACTOPSYff NbiNGS A'1AILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES Q NO
<br />no, street, factory, office building, conk
<br />soils
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />POODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24s On the lfdsls of examination enWor Investige Ion, in my opinion 'dsadi oiksun*4 6t
<br />•gra tint#, date and place and due to the ceuse(s) stated. (Signatureaattrikti. .,
<br />24d. TIME
<br />IOUNCED DEAD...
<br />26a. HAS ORGAN OR TISSUE DQNATH: N$EEN CONSIDERED?
<br />❑YES JNQ
<br />26b. WAS CONSENT GRANTED? ;
<br />Not Applicable if 26a Is NO 1i'ES
<br />28a. REGISTRAR'S SIGNATURE
<br />6/4-46t-11
<br />28b. DATE FILED BY REGI#
<br />February 1, 2024
<br />ono., Day, Yr.)
<br />CO
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