|
STATE OF NEBRASKA
<br />�nt9nat�� rrflKKl1)C(Ifef. ?ertpriWlpp�, ?r4401'li'1111fKtt",,,.;:
<br />WHEN THIS COI' CARRIES THE RAISED SEAL OF STATE OPNEBRASKA CERTIFIES THE DOCUMENT BELOW TO
<br />"BEA TRUE
<br />OP. O.F T.NE 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 />DAT` OP.ISSUANCE
<br />11/9/2022
<br />LINCOLN, NEBRASKA
<br />[1 DLCEDEter LAME (#fret, Middle, Last, Suffix)
<br />i[ Robort Dean Real
<br />22401 3,5:7
<br />202304871
<br />?&
<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 />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wood Rive,
<br />Nebraska
<br />mum
<br />D977
<br />ER
<br />5a. AGE - Latit Blithday.
<br />(Yrs.)
<br />75
<br />tib. FACILiTY•NAME Of ncthist (tution, give street and number)
<br />a Grand Island Regional Medical Center
<br />• it 013,Y OR TOWN OF DEATH (Include Zlp Code)
<br />Grand Island 688 3•
<br />9e. RESIDENCE -STATE
<br />Nebraska
<br />Ob. COUNTY
<br />Hall
<br />9d .sTRBET AN4t NUMBBi
<br />609 F til Street
<br />MARITAL':STATOSAT TIME OF DEATH ❑ Married 0 Never Married
<br />0 Married, but separated ❑Widowed 0 Divorced ❑ Unknown
<br />FATHERS AME 4 MIt,
<br />»0.ona.rd
<br />13. EVER IN tt S ARMED FORCE!
<br />(Pas, No, or Unk.) Yes 09/
<br />6 METHOD OF DISPOSITION
<br />Burial :': ❑Donetion
<br />emetivn d Entamb tient
<br />oval '' . ❑ Other;(Specify)
<br />Middle, Last, Suffix)
<br />Give dates of service if Yes.
<br />1966-09/19/1968
<br />r1 RA
<br />fib. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE or DEATH
<br />HOSPITAL ] .tnpatietit
<br />❑ ER)Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Wood River
<br />HOURS
<br />MINS.
<br />3.:GATE OF DEATH EMs, Di
<br />October 2, 2Q22
<br />6. DATE OF BIRTH'#Mo Day,:Yr.j
<br />Mat' 241,1:
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />7
<br />9f. ZIP CODE
<br />68883
<br />9g (N$DE CITY L4MI'TS i
<br />lab: NAMEOF SPOUSE (First,Middle, Last, Suffix) If wife, giv,,
<br />Betty A Reimers
<br />12 MOTHER'S -NAME (First,
<br />Barbara J Hyke
<br />14a. INFORMANTNAME
<br />Betty A Carlson -Real
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCov
<br />16b. LICENSE NO.
<br />1191
<br />Middle, Maids
<br />. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Wood River Cemetery
<br />17a. FUNERAL $IOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Wei )=ur era( Home, 1123 W. 2nd, Grand island, Nebraska
<br />PAR
<br />Ergot los c�
<br />Y
<br />error
<br />CAUSE OF DEATH '(See .i:nstructlert
<br />Wood River
<br />14b. RELATIONSHIP TO
<br />Spout
<br />16c. DATI
<br />Octob
<br />In iNllvents--dieseses,:intones, orcomplications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest.
<br />ulsr fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If neceesa
<br />IMMEDIATE CAUSE:
<br />a) Pulseless electrical activity
<br />a
<br />0
<br />tluantially list rondiah
<br />ant ,:beading to the cautgl,
<br />00lirms a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Efl theUMDERL.YINGCAU$E c)Non: small cell lung cancer
<br />(alseate er inJutythat initieted'..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Puimonary embolus
<br />5 18. PART IL OTt#ER SIGNBF:CANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in P
<br />acute gastrointesttnal b(eedllg, peptic ulcer disease, acute blood loss anemia, atrial fibritlation, coronary artery disease, die
<br />mellitus type 2, morbid obesity, hypertension, hyperlipidemia
<br />ART I.
<br />EMALEz
<br /># pragnent wltlNn p*at,year
<br />rNgl*nt at1tm¢ of deatls.
<br />at pr •gnanti but preata It Within 42 days of death
<br />pregnant, but prognoiit 43 days to 1 year before death
<br />nom N Iuagnv wt hh1 the past year
<br />ATE OF tNJ(JRY
<br />1
<br />22d iNJURY AT WORK?
<br />E] YES El NO
<br />c
<br />tQCA1'1C
<br />0
<br />21a. MANNER QF DEATH
<br />®. Natuni ❑ Nont(.clde
<br />❑ AceldaM ❑ Panding ImMatigetlen
<br />❑ Suicide ❑ Coutd not be determined
<br />22b. TIME OF INJURY
<br />21b<IF TRANSPORTATION INJURY
<br />❑ DrWisiOperator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />49. WAS MEl2`AL
<br />EXAid1NEF
<br />hetes OR CORONER r 1ACTrt
<br />❑ YES i NO
<br />21c. WAS AN AUTOPSY PIIpRME;"
<br />❑YES Q NO
<br />21d. WERE AUTOPSY taros AIIA(i:ABtB
<br />TOCOMFCETE; CAUSE OF DEATH?
<br />❑ YES [ NQ
<br />22c. PI -ACE OF INJURY A* hone, farm, street, factory, office building, collet Ion
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />& NUMBER,APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 2, 2022
<br />CITYJTOWN<
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />(dobe( 4,>2 10:19 AM
<br />SC. n* rtiti W at at my knowledge,, death occurred at the time, date and place
<br />and due td the bause(s) stated. (Signature and Title)
<br />Jay C. Anderson, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. T1
<br />24d. ?IME PRONOU
<br />D DEAD..;(
<br />4e. Do the pests of examination and/or lnvastlgetion, hi my epinirrOdeath ocoui
<br />the timer Oats and place and due to the cause/el stilted. (Sigeaturs and i
<br />28a. HAS ORGAN OR r • ATION BEEN CONSIDERED?
<br />❑,YES •
<br />2b DID TOBACCO USE CONTRtBUTE TO THE DEATH?
<br />I I YEIi NO ❑ PROBABLY UNKNOWN
<br />27 NAPni tiTtV4N0 ADDRESS OF CERTIFIER (Type or Print
<br />Jaye: Afiderson, MD, 729 North Custer Avenue, Grand Island, Nebratka,8803
<br />I28a. REGISTRAR'S SIGMA'
<br />28b. WAS CONSENT GRAN D?
<br />Not Applicable if 28e Ie N(
<br />28b. DATE FILED BY REOISTRAI
<br />October 12, 2022
<br />0
<br />AY, Yr.
<br />
|