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1
<br />Ann
<br />( STATE OF NEBRASKA
<br />digrahtJFsex�" .astg(VVV?IY,I1IDkcs
<br />aaso.=° �.?•:VVV.7t1'114ipssa..
<br />WHEN ; THIS ;;;' COPY CARRIES THE RAISED ; SEAL OF ; THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A i `ROE" COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL:. RECORDS
<br />DATE OF ISSfANCE
<br />7i112016 2 0 2 u; 2 0 7
<br />LINCOLN, NEBRASKA
<br />CEDENVS-NA
<br />ileen
<br />4 ;C1Tf .I ND?STATE
<br />Firs
<br />uns
<br />Iddie
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT DF HEAET'H ANI> HHUMAN SERVICES
<br />EAT.H:.
<br />Last, S
<br />x)
<br />CERTIFICATE .0
<br />E .11IIR ITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Spalding, Nebraska'
<br />7. SOCIAL SECURITY NUMBER
<br />5-O2-1446::
<br />rrv.NAMSi+'(kr)i
<br />131:1 N. Geddes
<br />Institution, give street and number
<br />8c. CITY OR TOWN OF DEA
<br />Grand, Island 68801
<br />ea: RESICENC.E-STATE.:
<br />Nebraska > .:
<br />9d. STREEt AND
<br />ts
<br />1311 N. Geddes St.
<br />toe: MARITAL STATUS AT. TIME OF DEATH ® Married ❑ Never Married
<br />known
<br />r Widowed Divorced Un
<br />Alfarr(eifi; tut(atepa: atei!":': ❑ ❑ ❑
<br />(I
<br />e Zip Code)
<br />9b. COUNTY
<br />Hall
<br />8a.:AGE'4as1:8lit/
<br />BSA'
<br />1. FATf#ER'S-NAME (First Middle, Last, Suffix)
<br />Robert William Moore
<br />t 13 ;EVER IN: U.S. ARMED FORCES? Give d
<br />8;: {Yes No, c. Unk.) NQ:
<br />METHOO:QF,pisPiYStflON
<br />F` BUr *t Donation
<br />® Cremation 0 Entombment
<br />R@mvv'al `❑ Other.(Specify)
<br />E 22a. DATE OF INJURY
<br />8
<br />tMMEDiAiE CAUSE (Final
<br />disease or condition resulting
<br />es of service if Yes.
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />y
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑D ::; . .
<br />CITY`OR Ti3NlN:
<br />Grand island
<br />1 DAY
<br />MINS.
<br />3. DATE OF
<br />une 16, 201,6
<br />Day,Yr)`
<br />6. DATE OF BIRTH (2Aoz(Saly,;Yt :I
<br />February 14,1
<br />OTHER ❑ Nursing Home/LTC
<br />Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />. ZIP CODE
<br />68801
<br />18b. NAME OF:SPOUSE (First,... Middle, Last, Suffix) if wife, give maiden name,.
<br />ireimis'>Wayne ;BTutt8
<br />12. MOTTHERS-NAME (First, Middle, Maiden Surname)
<br />Elizabeth Josephine Clark
<br />4a. INFORMANT -NAME .
<br />Dennis Wayne Brur1S
<br />1.fib.: LICENSE NO.
<br />Y
<br />NO
<br />14b. RELATIONSHIP TO DEOEDENT
<br />Husband
<br />16c. DATE (
<br />June 18, 20
<br />.i
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1 ra. FUNERAL ttfSME NAME AND MA LING ADDRESS (Street, City or Town, Stiltei '
<br />All Faiths Fti fetal Home, 2929 S. Locust Street, Grand Island. Nebraska'
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examol
<br />)
<br />gi:eyeAk• -diseases, injuries, or complications -that directly caused the'itneth, pa NOT enter ihrmff$ gvrfds such as cardiac arrest,
<br />or vetltricKat fibrinogen without showing the etiology. DO NOT ABBREVIATE. Efiter.onlyrone:cau'ee on:al IOW:Add additional tines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Metastatic Sarcoma, Of Left Thigh
<br />esfi*Siany:S# 40Ol boss :tf
<br />y;':Ietdiny.to-pu ca'vse::lilted
<br />Enter the UNDERLYING CAUSE
<br />idiseaea:er.:irtjuryttat tnM4ied ..
<br />::t a '1'0 s resulting In de*th)
<br />DU
<br />c)
<br />OR AS A CONSEQUENCE OF:
<br />TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQU
<br />d)
<br />NCE OF:
<br />1
<br />20.
<br />PART II.OTHER SI(#NI
<br />ALE::
<br />ICANT CONDITIONS-Condltlone contributing to the death but not resulting in the underlying cause given in PART I.
<br />n paet.vr ar
<br />Pregnant at time of death
<br />Not.P.regnart, but Pr..egwkhin 42 days of death
<br />jotpiydhertt tint pref nantnant:wdays to t year before death
<br />Unknown If:Riayn*tt�wit timi the past year
<br />21a. MANNER OF•D.EATH
<br />® Natural ❑ Herricide
<br />❑ Accident
<br />0 Suicide
<br />❑ Pending Investigation
<br />❑Could not be Apteimmed
<br />21b, IF TRANSPORTATION INJURY
<br />DAvanOperator
<br />❑ Passenger
<br />Pedestrian
<br />.oilie+.(Specify)
<br />STATE
<br />Nebraska : >;
<br />801
<br />APPROXIMATE)NTEH A
<br />onset to deat11
<br />Years
<br />p:de
<br />9. WAS MEDICAL EXAMIN
<br />OR CORONER CONTACTED
<br />❑ YES ::41:N4
<br />21c.WASA
<br />❑ YES
<br />AU
<br />21d. WERE AUT
<br />TO COMPLE
<br />❑ YES
<br />AY
<br />E
<br />y, Yr.)
<br />22b. TIME OF INJURY
<br />2c. PLACE OF INJURY -At ho
<br />e, farm,. Street, factory, office building, constru
<br />. 22d.:INJURY A'T YViORK
<br />YES ; ONO
<br />22f.
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. DfRO:NOUNCED DEA
<br />o., Day, Yr.)
<br />24b.
<br />24d. TIME P
<br />24e. On the basis of *semi on end/or Investigation, In ley opinion desSi ocou
<br />the time, dab and pia and due to the cause(e)Slated. Istgnature '_' •..•
<br />26a. HAS ORGAN .:OR Tf8sue ?ONA'#I
<br />❑ YES ;:;: <ig):'NO:
<br />10
<br />DESCRIBE HOW INJURY OCCURRED
<br />ET & NUMBER, APT.NO.
<br />:23a. DATE QE::( EATH (Ma., Day, Yr.)
<br />.I6:201
<br />23ti, DATE SIGNED (Mo., Day, Yr.)
<br />:.''201
<br />CITY/TONN
<br />23c. TIME OF DEATH
<br />02:1•AM
<br />death occurred at the time, date and place
<br />bted. (Signature and 'Mist
<br />T43(3ACt 1 USE CONTR18UTE TO THE DEATH?
<br />0 PROBABLY 0 UNKNOWN
<br />NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S..tiageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />�`{�
<br />�y:y it am.::
<br />.;...;_
<br />BEEN CONSIDERED?
<br />26b, WAS CONSEN
<br />of Applicable If 26a Is NO j!'E
<br />28b. DATE FILED BY
<br />June 29, 2016
<br />Yr)
<br />
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