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<br />WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTFIES TiE: BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE IkOt ,.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISF� SI€Tf01lF_ //CHI;,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />- -_- 1AAMEY.S. CJ6*#*R
<br />4/6/2004 200404395 AfiTAlliT
<br />LINCOLN, NEBRASKA HEALTH•ANkAASEIiVICE$1 jEr'
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAH'SERVI�FIIh4 IEE ANb SE�PORT
<br />VITAL STATISTICS -7 - Q 4 03745
<br />CERTIFICATE OF DEATH - _ -
<br />1. DECEDENT- NAME FIRST MIDDLE, LAST
<br />2 SEX
<br />3. DATE OF DEATH. /Month. Day. Year)
<br />Robert LeRoy Frank !
<br />Male
<br />March 26,2004
<br />4. CfTY AND STATE OF BIRTH (d rat in USA.. name cowmy/
<br />5a AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER i DAY
<br />6. DATE OF BIRTH /MOrN4. Day. Year)
<br />Sioux City, Iowa
<br />n ".) 53 i'
<br />August 12, 1950
<br />"IDS. i DAYS
<br />5c. HOURS MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />8a" PUCE OF DEATH -
<br />506 -66 -4326
<br />HOSPITAL „ Inpea.nt OTHER: :® Nune, Home
<br />❑ ER Ougl *M ❑ Residence
<br />-V1
<br />C
<br />Tn
<br />n
<br />to
<br />=
<br />k CITY. TOWN OR LOCATION OF DEATH _ _ _
<br />c
<br />8a. COUNTY -OF DEATH - - - - -
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />9s. RESIDENCE - STATE
<br />C7
<br />9e. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Aretlyd'ng2Tp Code)
<br />9a. INSIDE CRY NMfTS
<br />s"°
<br />I Hall
<br />O
<br />Fb"
<br />Yes K] No ❑
<br />Ei
<br />11. ANCESTRY (a.%. Italian. Mexican. German, etcl
<br />12 ❑ MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (I/ wife. give maiden name)
<br />etc.)(specify)White
<br />YY1L
<br />" "/American
<br />I
<br />c X�
<br />N
<br />trt
<br />>
<br />Eka fi fary or Secondary 10 -12) College 11 -4 or 5 -t
<br />G
<br />�e�A
<br />i.11lne ` Wr).tor I
<br />Mechanical
<br />1& FATHER - NAME FIRST MIDDLE LAST
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Z
<br />TV
<br />CL
<br />SLINFORMANT-NAME
<br />X
<br />11 Linda Bagley
<br />t9b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE DP)
<br />Linda Bagley, 3030 Midway Road Grand Island Nebraska 68803
<br />20. - SONAT E 8 FUE N O.
<br />&/�9/
<br />_3
<br />21b. DATE 21a
<br />TWestlawn
<br />CEMETERY OR CREMATORY NAME
<br />X❑ Serial ❑ Removal
<br />March 29, 2004
<br />Memorial Park
<br />22a.TUNERALHOft,AAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston- Sondermarin
<br />❑ C"matierl ❑ Dornatwn
<br />< c�,
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE, ZIP)
<br />601 North Webb Road Grand Island,Nebraska 68803
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (c)) I Interval between onset and death
<br />PA1�angrene -left lower extremity :- fear:}
<br />DUE TO, OR AS A CONSEOUENCE O - 1 Interval between onsetand death
<br />Severe peripheral vascular::-disease several years
<br />(b)
<br />DUE TO, OR AS A CONSEOUENCE OF: I Interval between onset and death
<br />o y�
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />p -n
<br />O
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART ._ PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />"Anorexia, Depression, & Schizophrenia ,Ages
<br />QV
<br />Ca
<br />= rT7
<br />117,
<br />28b. DATE OF INJURY (Ma. Day. Yr)
<br />26c. HOUR OF INJURY
<br />Zed DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />m
<br />-,D
<br />D ou
<br />O
<br />=
<br />El HorniCida Investigation
<br />yea ❑ No ❑
<br />27a DATE OFADFATH (MO.. Day. Yr.)
<br />We. DATE SIGNED (Ab.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />March 26, 2004
<br />�g_
<br />=
<br />M
<br />27b. DATE SIGNED (MO.. Day. Yr)
<br />En
<br />2Bc. PRONOUNCED DEAD (Mo_ Day. Yr.)
<br />Cn
<br />CD
<br />K y
<br />< J
<br />March 29, 2004
<br />- �
<br />N
<br />- rt
<br />W
<br />CD
<br />B
<br />8$?
<br />a $ °
<br />27d. To the best of my knowled e. death occurred at the time ate app place and due to the
<br />28e. On the basis of examination ardor investigation• in my opinion death occurred at
<br />causelsl slated
<br />pill
<br />g 6
<br />the fime, date and place and due w the cause(s) stated
<br />co
<br />(Si nature and Title
<br />(Signature and Title) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES ❑ NO 10 UNKNOWN
<br />N
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Phnt)
<br />Dr. Neena Biswas, M.D., VAMC J2201 N_ Broa ell, Grand Island,.NE 68801
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />APR 2 2004
<br />cri
<br />N
<br />WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTFIES TiE: BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE IkOt ,.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISF� SI€Tf01lF_ //CHI;,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />- -_- 1AAMEY.S. CJ6*#*R
<br />4/6/2004 200404395 AfiTAlliT
<br />LINCOLN, NEBRASKA HEALTH•ANkAASEIiVICE$1 jEr'
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAH'SERVI�FIIh4 IEE ANb SE�PORT
<br />VITAL STATISTICS -7 - Q 4 03745
<br />CERTIFICATE OF DEATH - _ -
<br />1. DECEDENT- NAME FIRST MIDDLE, LAST
<br />2 SEX
<br />3. DATE OF DEATH. /Month. Day. Year)
<br />Robert LeRoy Frank !
<br />Male
<br />March 26,2004
<br />4. CfTY AND STATE OF BIRTH (d rat in USA.. name cowmy/
<br />5a AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER i DAY
<br />6. DATE OF BIRTH /MOrN4. Day. Year)
<br />Sioux City, Iowa
<br />n ".) 53 i'
<br />August 12, 1950
<br />"IDS. i DAYS
<br />5c. HOURS MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />8a" PUCE OF DEATH -
<br />506 -66 -4326
<br />HOSPITAL „ Inpea.nt OTHER: :® Nune, Home
<br />❑ ER Ougl *M ❑ Residence
<br />6b. FACILITY - Name /Mnof insftiulion, give street and numbeQ
<br />r GrandIsland VAMC Nursing Home Care Unit
<br />❑ DOA ❑ Omer (Specdv)
<br />k CITY. TOWN OR LOCATION OF DEATH _ _ _
<br />8d. INSIDE CITY LIMITS
<br />8a. COUNTY -OF DEATH - - - - -
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />9s. RESIDENCE - STATE
<br />9b. COUNTY
<br />9e. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /Aretlyd'ng2Tp Code)
<br />9a. INSIDE CRY NMfTS
<br />Nebraska
<br />I Hall
<br />Grand Island
<br />13030.Midway Road 68803
<br />Yes K] No ❑
<br />10. RACE - (e.g.. White. Black. American kxkan.
<br />11. ANCESTRY (a.%. Italian. Mexican. German, etcl
<br />12 ❑ MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (I/ wife. give maiden name)
<br />etc.)(specify)White
<br />YY1L
<br />" "/American
<br />I
<br />NEVER DIVORCED
<br />MA I
<br />14a. USUAL OCCUPATION /Give kind of work done duhng moat 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />Eka fi fary or Secondary 10 -12) College 11 -4 or 5 -t
<br />G
<br />�e�A
<br />i.11lne ` Wr).tor I
<br />Mechanical
<br />1& FATHER - NAME FIRST MIDDLE LAST
<br />FIRST MIDDLE MAIDEN SURNAME
<br />�17.MOTHER
<br />Leander F. Frank
<br />Esther Mae Perschy_
<br />1& WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />SLINFORMANT-NAME
<br />�`es ask.' V19 ?YMa`"�X/7tT"to 2/11/72
<br />11 Linda Bagley
<br />t9b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE DP)
<br />Linda Bagley, 3030 Midway Road Grand Island Nebraska 68803
<br />20. - SONAT E 8 FUE N O.
<br />&/�9/
<br />21 a METHOD OF DISPOSITION
<br />21b. DATE 21a
<br />TWestlawn
<br />CEMETERY OR CREMATORY NAME
<br />X❑ Serial ❑ Removal
<br />March 29, 2004
<br />Memorial Park
<br />22a.TUNERALHOft,AAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston- Sondermarin
<br />❑ C"matierl ❑ Dornatwn
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE, ZIP)
<br />601 North Webb Road Grand Island,Nebraska 68803
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (c)) I Interval between onset and death
<br />PA1�angrene -left lower extremity :- fear:}
<br />DUE TO, OR AS A CONSEOUENCE O - 1 Interval between onsetand death
<br />Severe peripheral vascular::-disease several years
<br />(b)
<br />DUE TO, OR AS A CONSEOUENCE OF: I Interval between onset and death
<br />insulin dependant diabetes ;several years
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART ._ PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />"Anorexia, Depression, & Schizophrenia ,Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes No
<br />20111.
<br />28b. DATE OF INJURY (Ma. Day. Yr)
<br />26c. HOUR OF INJURY
<br />Zed DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />29. P QF INJU `M Rome, hrm. easel factory
<br />Itlt^4 Syadg9.
<br />28g. LOCATION STREET OR R.F.D. NO. CRY OR TOWN STATE
<br />El HorniCida Investigation
<br />yea ❑ No ❑
<br />27a DATE OFADFATH (MO.. Day. Yr.)
<br />We. DATE SIGNED (Ab.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />March 26, 2004
<br />�g_
<br />=
<br />M
<br />27b. DATE SIGNED (MO.. Day. Yr)
<br />27d TIME OF DEATH
<br />2Bc. PRONOUNCED DEAD (Mo_ Day. Yr.)
<br />28d PRONOUNCED DEAD (Hour)
<br />K y
<br />< J
<br />March 29, 2004
<br />07:15 A M
<br />N
<br />- rt
<br />M
<br />B
<br />8$?
<br />a $ °
<br />27d. To the best of my knowled e. death occurred at the time ate app place and due to the
<br />28e. On the basis of examination ardor investigation• in my opinion death occurred at
<br />causelsl slated
<br />pill
<br />g 6
<br />the fime, date and place and due w the cause(s) stated
<br />(Si nature and Title
<br />(Signature and Title) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES ❑ NO 10 UNKNOWN
<br />13 YES ❑ NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Phnt)
<br />Dr. Neena Biswas, M.D., VAMC J2201 N_ Broa ell, Grand Island,.NE 68801
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />APR 2 2004
<br />.a -
<br />
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