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WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 6/2/2004 ANLEY S. COOPER ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM COPY 200408329 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS /� O /� r.PR TTFTC A TP (1F 1lF A Tu 4 8 4 0 DECEDENT - NAME FIRST MIDDLE LAST y• 3. DATE OF DEATH IMonth. Day, Yea i COPY 200408329 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS /� O /� r.PR TTFTC A TP (1F 1lF A Tu 4 8 4 0 DECEDENT - NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH IMonth. Day, Yea Betty Joan Siemers Female May 21, 2004 CI7V AND STATE OF BIRTH lI /no! in USA., name country/ E -Last Birthday UNDER 1 YEAR UNDER 7 DAY 6, DATE OF -BIRTH lfMOnth. Day Year) 56 MOs. I DAYS Sr. HOURS' MINS Cairo Nebraska s.1 60 May 28, 1943 SOCIAL SECURTIY NUMBER Ela 8a. PLACE OF DEATH 508 -54 -4062 HOSPITAL: Inpatient OTHER: ® Nursing Home DUE TO, OR AS A CONSEQUENCE OF ER Outpatient Residence FACILITY - Name (t/nol institution, give street and number) Beverly flea lthcare-Lakeview DOA I' ''� Interval between onset and death I Other (Svecdvl _ CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island - 2 Hall 27a. DATE OF DEATH (Mo.. Day. Yr,) 2 Yes No 20a. DATE SIGNED (Mo.. Day. Yr) 2 RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (including Zip Code) Be. INSIDE CITY LIMITS Nebraska Mall Grand Island 5076 Abbott Rd., 68803 Yes No IN RACE - (e.g., White. Black. American Indian. 11. ANCESTRY fe.g.. Italian. Mexican. German, etc) '12. (�(j MARRIED ❑WIDOWED Lf 13. NAME OF SPOUSE p/ wile. give maiden name) hlie�l (;e'man /American ❑� NEVER DIVORCED MARRIE Robert L. Siemers a. USUALPQOCCUPATION - /Give kind a /work done during most T°eac[ler even if refired) 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed( Elementary or Secondary 10 -12) _ College 11 -4 or 5 -1 '!1}Ti - -] T FIR R . NAM FIRST School -- - - -- °� -- �l. mv�ncn FiHbI MIDDLE - MAIDEN SURNAME. Belmar (NMI) Perkins E Elaine Rube WAS DECEASED EVER IN U.S. ARMED FORCES7 19a. INFORMANT - NAME (Yes no of unk.) (If yes. give war and dates of services) No Robert L. Siemers b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 5076 W Abbott Rd, Grand Island, Nebraska 68803 EMBALMER - SIGNAT E a LICENSE NO. 211 aa. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME °✓/ 1037 A Burial R Removal 05/29/2004 Mount Pleasant Cemetery a. IU R HOME - NAME III IF FEMALE, WAS THERE A 2 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Kleine Funeral Home F� Cremation 0 Donasen Cairo, Nebraska EXAMINER OR CORONER? b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) ,Yes No Y Yes D No 3213 AV North Front St Grand Island, NE, 68803 26b. DATE OF INJURY (Mo.. Bay. Yr) 2 IMMEDIATE CAUSE )ENTER ONLY ONE CAUSE PER LINE FOR Is). (b;,ANO (cr` ) PART Interval between onset and death ., ✓ /`j DUE TO, OR AS A CONSEQUENCE OF I lnfery ill between onset and death I M DUE Tn o c - -` "" " """ "' `�'- "` ° ° "'�` �' _ I' ''� Interval between onset and death I fcl 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE OTHER SIGNIFIC NT CONDITIO - Conditions contributing to the death but not related PART I III IF FEMALE, WAS THERE A 2 24 AUTOPSY 2 25. WAS CASE REFERRED TO MEDICAL �; ��/ / PREGNANCY I IN THE PAST 3 MONTHS? E EXAMINER OR CORONER? (Ages 10 -54) Yes No , ,Yes No Y Yes D No a. 2 26b. DATE OF INJURY (Mo.. Bay. Yr) 2 26c. HOUR OF INJURY 2 26d. DESCRIBE HOW fN.;JRY OCCURRED Accident f Undetermined L M Suicide Pending 2 26e. INJURY AT WORK 2 Lp EEppp� pp M 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Y Yes 1:1 No 27a. DATE OF DEATH (Mo.. Day. Yr,) 2 20a. DATE SIGNED (Mo.. Day. Yr) 2 28b. TIME OF DEATH May 21,2004 > NU >s_ M M 276. DATE SIGNED /Mo. Day. Yr.! 2 27c. TIME OF OFJ TH " 28c. PRONOUNCED DEAD (Mo.. Day, Yr.; 2 28d. PRONOUNCED DEAD (Maur! " 0 2 May 26 2004 9 9:55 am M w ww =° M z M 27d. To the best of my kncwledge, dea�dcurred at the time, date and place and due to the U 289. On the basis of examination and, or investigation, in my opinion death occurred at causefs) slated . t the time, dale and place and due to the causels) staled. Si nature and Title) / `-' I ISi nature and Title) jf� .DID TOBACCO USE CONTRI TO THE DEATH' 3 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 3 30.b WAS CONSENT GRANTED? YES NO � UNKNOWN Y YES NO Y YES - NO NAME ANA -Ar 0-ESS OF CERTJFIER ro HYS!C!AN1 CCF! t _..__..____. __..... ._.. ,. ...- .- -..... .........,.�.........,. n„OPiNFY IrYPewrnnr/ Dr Jane A McDonald. MD 800 Alpha Grand Island,NE 68803 'a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) JUN - 1 204 It