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rs4gq� tilt yi . g3 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 />BE A 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 />DA'TEtF ISSUANCE
<br />12/2/2023
<br />LINCOLN, NEBRASKA
<br />202401 551
<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 />CEDENT',S-NAME(First, Middle, Last, Suffix)
<br />obert ,Henry VMlalker
<br />4.; CITYAND STATE OR''TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Limon, Colorado
<br />7: SOCIAL SECURITY:NUMBER
<br />522-34.1795
<br />8b'FACILITY-NAME(1f'not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />Bc:GrrY
<br />EllOrsin
<br />OR: TOWN OF DEATH (Include Zip Code)
<br />d kalerlti 68$:{13
<br />9a:RESIDENCESTATE
<br />Nebraska
<br />94.4TREET AND NtiMBER
<br />X751 N l%Jtrrth Rd
<br />9b. COUNTY
<br />Hall
<br />5a.:AGE • •Last•Btrthday
<br />(Yrs.)
<br />sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />6s.• PLACE of DEATH
<br />HOSPITAL Inpatient
<br />❑ ERioutpatient
<br />D DoA
<br />108 MARITAL:; STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />11. FATHER'S.
<br />Unknown
<br />ME (First
<br />Unknown
<br />Middle, Last, Suffix)
<br />13,;EVER IN U.S.ARMED FORCES? Give dates of service If Yes.
<br />(Yee, No, or Unk.) Yes 1952-1954
<br />18. METHOD OF DISPOSITION
<br />.0,130)1 0)) [ DotfMion
<br />•Cremation ❑ Entombment
<br />Removal: ❑ Clther (Specify)
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />HOURS
<br />MINS.
<br />23 17313
<br />3. DATE OF DEATH'(Mo Day, Yr
<br />Decembe€12, 2023
<br />6. DATE OF BIRTH
<br />October: 3, 183E
<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 />9f. ZIP CODE
<br />68803
<br />1:Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If
<br />Lois ' Tuttle
<br />14a. INFORMANT -NAME
<br />David Walker
<br />18..EMBALMERSIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S -NAME (First, Middle,
<br />BUelah :Unknown
<br />16b. LICENSE NO.
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL;HOME. NAME AND MAILING ADDRESS (Street, City or Town, Stats)
<br />All P ithS Funeral Home, 2929 S. Locust Street, Grand Island;' Nebraska for
<br />Other (S Cifv)
<br />18.PART I. Enter
<br />CAUSE OF DEA'TH (See instruttlonj and examples)
<br />omin ascents- .diseases, injuria, or complications -that directly caused the death. DO NOT .Mer terminal events such as cardiae arrest,
<br />respiratory arm or ventricular ffi dII.tlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />Ho$plce F$ 111ty
<br />9g INSIDE CITY.LIMITS'
<br />13:,0c
<br />Maiden Sumame)'
<br />14b. RELATIONSHIP"
<br />Son
<br />16c. DATE (5/14, Day, Yr.)
<br />December. 1 3.2023
<br />STATE
<br />Nebraska
<br />EDENT`
<br />IMMEDIATE CAUSE:
<br />IMMEDIAtECAU$E(Ft.H a)Cardiopulmonary arrest
<br />d(# ueoraonlltlidnresutittg
<br />in'dwath)
<br />tkgwntlally list conditions, if
<br />any, laadtnq to tat ecu,. lined
<br />taw theUNDERLYte CAU$E
<br />(disease or Injury Bret•IniHeiad
<br />the events reaching in: dear
<br />LAST ..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Sepsis
<br />DUE TO, OR A CONSEQUENCE OF:
<br />c) Pneumonia
<br />1:$1E TO, OR AS A CONSEQUENCE OF:
<br />d) Influenza
<br />18..PART H OTHER SIGNIFICANT CONDITIONS -Conditions contributing to
<br />Heart failure, atrial Sbrlilation, coronary heart disease
<br />28. IF FEMALE::.
<br />Not pregnant with(n
<br />regpaetyeer
<br />r» pt asti4i fie of thath
<br />NotpregrtaIt, but pregnant within 42 days. of death
<br />❑'. Not pr.gnaM, but pregnant W days to 1 year before death
<br />Unknown 1/ QregnaM wlththtn the pest year..
<br />22a ;'DATE OF!iUJURY (Ma, Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />he death'1
<br />21e. MANNERO^�iF DEATH
<br />r
<br />® Natural t../ Horpietde
<br />❑ Accident ❑ pending intre5tigation
<br />0 Suicide 0 Could not be determined
<br />APPROXIMATE INTERVAL
<br />i on
<br />5 Minut
<br />onset`
<br />to death`
<br />10 Days
<br />.,onasllo death.:'.
<br />' 10 C1il4
<br />natresultinq;in thaunderlying cause given in PART 1.
<br />22b. TIME OF INJURY
<br />22c. PLAC
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />°CATION;( P 1Nr1URYY STREET & NUMBER, APT.NO.
<br />13a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 12, 2023
<br />210, tF.TRANSPORTATION INJURY
<br />❑ Ddvar/Operator
<br />:❑ Paaaenger
<br />❑PedesMan
<br />❑ Other (Specify)
<br />19. WAS MEDICAI. EXAMINER
<br />ORCORONERCONTACTE 7
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY P SF
<br />0ES No
<br />21d, WERE AUTOPSYFtNDING$AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?'.
<br />❑ YES ❑ NO
<br />OF INJUR'Y.At horne iarm,, street, factory, office building, construction
<br />CITY/TOWN'
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />December 19, 2023 06:45 AM
<br />... ....y ge, at the time, date and place
<br />28tl tethe bear of tn. Imowletl death occurred
<br />and due f011ie Outlets) stated. (Signature and Title)
<br />Logan C Collins, MD
<br />D TOBA C•ig
<br />25. DI CO U.SE;„ ONTRIBUTE TO THE DEATHS 26a. HAS ORGAN OR TISSUE DONATION. BEEN CONSIDERED?
<br />YES '❑ NO ❑PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />PDO
<br />24c., PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNOED DEA
<br />24e. t)n the t}eais of examination and/orinveetigation, in my opinion tleath aocUntdtt
<br />the dnul, date and place and du. to tat caues(a) stated )Signature 4P5f tee)
<br />0 YES NO
<br />21 NAME,11Y E NrJrADCRESS OF t°ERTIFIER (Type or Print
<br />oan Collins, MD, 3533 Prairieview St, Grand Island, Nebraska, 68801
<br />28a. REGISTRARS SIGNATURE
<br />67 -dr ,• ,rt. -r *-
<br />26b. WAS CONSENTGRANT'ED?
<br />Not Applicable 8 26.18 NO ❑ YES. 0 NO
<br />28b. DATE FILED BY REG
<br />December 20, 2023
<br />
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