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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REEBRD_2Q11 FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST417aT1 v_SL TLM- =WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE -
<br />JUN 15 2005 __ _E�►'s:LCOOPER
<br />67OZOG 10 ASSISTANT:$TATE REGISTRAR
<br />LINCOLN, NEBRASKA HEAHINQtAN SEI"fVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANC1c Ann 6F]P ORTn pp �^,
<br />CERTIFICATE OF DEATH - -U 5--.-.0-2-.8 9. � _
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2, SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Robert E. Caner Male _March 10.x.- 20.05
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo.. Day, Yr,)
<br />(Yrs.) MOS. BAYS HOURS MINS.
<br />Giltner, Nebraska 81 May 12, 1923
<br />7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH
<br />507 -38 -5145 _ HUPITAL ❑ Inpatient OTHER: )0<IJursingHome /LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (if not institution, give street and number)
<br />U ER;Oulpatient ❑ Oeae, ",ant's Homy
<br />Grand Island Veterans Haw
<br />U OL14 U Other (Specify)
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island, Nebraska 68803 Hall County - _....
<br />9a. RESIDENCE -STATE 91 COUNTY 9a CITY DR TOWN
<br />Nebraska I Hall Grand Island
<br />9d. STREET AND NUMBER go. APT. NO Of, ZIP CODE Og. INSIDE CITY LIMITS
<br />2300 W. Capital Ave. 1 68803 (1 YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />❑ Married, but separatedXXWldowed Q Divorced ❑ Unknown
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />John Comex Lorena Connell
<br />13. EVER IN U.S. ARMED FORCES. Give dates of service it yes. 14a. INFORMANT -NAME 14b, RELATIONSHIP TO DECEDENT
<br />(Yes,no,orunk.) Yes 4/4/1945- 8 -8 -19 6 Janis Wells Friend
<br />'.1 15. METHOD OF DISPOSITION 16a. EMBA - NATU 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr. )
<br />❑Burial ❑Donation / ^/ /�J 1191 March 11, 2005
<br />r
<br />aCremation C3 Entombment 16d. CEMETERY, CREMA RY OR OTHER LOCAT CITY/TOWN STATE
<br />C3 Removal ❑ Other (Specify) Westlawn Memorial Park Crematory, Grand Island, NE 68803
<br />a. 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />1:
<br />Livingston- Sondermann Funeral Home, 601 N. Webb Rd., Grand Island, NE 68803
<br />18. PART I. Enter the chain of.eYents -- diseases. Injuries, or complications- -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular
<br />fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Imes If necessary.
<br />a
<br />March 10 2005
<br />IMMEDIATECAUSE:
<br />I
<br />onset to death
<br />contributing to the death but not resulting In the underlying
<br />(a) Cardiopulmonary Arrest
<br />e 3 Hours
<br />IMMEDIATE CAUSE (Final
<br />a
<br />disease or condition resulting
<br />DUE TO, OR AS A CONSEQUENCE OF: I
<br />onset to death
<br />In death)
<br />Eaz
<br />March 10, 2005
<br />Sequentially list conditions, If
<br />(b) Hypoxlc Encepha]_opathy with Choking Episole
<br />7 PayS
<br />any, leading to the cause listed - .._.
<br />-- - -- - - -...- --- ---- ...- ._.._........_......
<br />DUE TO, OR AS A CONSEQUENCE OF: I
<br />onset to death
<br />on line a.
<br />21 b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />Enter the UNDERLYING CAUSE
<br />(c) Dysphagia 1
<br />1 Year
<br />(disease or Injury that initiated
<br />Xf�NO
<br />-7
<br />the events resulting in death)
<br />DUE TO, OR ASA CON SEQUENCEOP: I
<br />onset to death
<br />LAST
<br />U YES NO ❑PROBABLY
<br />-,-.�.-. ____.
<br />L] Pregnant at time of death
<br />`
<br />1 Year
<br />23a. DATE OF DEATH (Mo,. Day, Yr.)
<br />(�
<br />24b.TIME OF DEATH
<br />a
<br />March 10 2005
<br />a u =
<br />18. PART If. OTHER SIGNIFICANT CONDITIONS-Conditions
<br />contributing to the death but not resulting In the underlying
<br />cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />a
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH R 240. PRONOUNCED DEAD (Mo., Day, Yr,)
<br />OR CORONER CONTACTED?
<br />Eaz
<br />March 10, 2005
<br />3 :10 -A.m Ea0 z
<br />m
<br />❑ YES XX NO
<br />20. IF FEMALE'
<br />21a, MANNER OF DEATH
<br />21 b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />23d.To the best of my knowledge, death occurred at the lime, date and place $ w 24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />�' M
<br />❑ Not pregnant within past year
<br />Matural U Homicide
<br />❑ Driver /Operator
<br />Xf�NO
<br />-� n 12 a0
<br />25. DIDTOBACCO USE CONTRIBUTETD HE DEATH?
<br />❑ Passenger
<br />Ell YES
<br />U YES NO ❑PROBABLY
<br />-,-.�.-. ____.
<br />L] Pregnant at time of death
<br />❑ AccldentU Pending Investigation
<br />No( Applicable If 28a Is NO U YES U NO
<br />_...........
<br />27. NAME, TITLE AND
<br />DADpRESSOFCERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type crPrint)
<br />M.A. Tompkins, M.D.,
<br />• Not pregnant, but pregnant within 42 days of death
<br />❑Suicide ❑ Could not be determined
<br />❑ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE 70
<br />281b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />• Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Other ( Specify)
<br />COMPLETE CAUSE OF DEATH?
<br />❑ Unknown it pregnant wllhin the past year
<br />U YES U NO
<br />22a, DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF
<br />INJURY
<br />m
<br />226, PLACE OF INJURY -AI home, farm,
<br />street, factory, office building, construction
<br />site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />I 22e, DESCRIBE HOW INJURY
<br />OCCURRED
<br />U YES L1 NO
<br />221. LOCATION OF INJURY • STREET & NUMBER, APT. N0, CITY/TOWN
<br />STATE
<br />,........--- ...... - --
<br />ZIP CODE
<br />4 0
<br />23a. DATE OF DEATH (Mo,. Day, Yr.)
<br />..........
<br />z 24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />a
<br />March 10 2005
<br />a u =
<br />1T7
<br />yy N
<br />Y
<br />a
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH R 240. PRONOUNCED DEAD (Mo., Day, Yr,)
<br />24d, TIME PRONOUNCED DEAD
<br />Eaz
<br />March 10, 2005
<br />3 :10 -A.m Ea0 z
<br />m
<br />V
<br />C
<br />cy
<br />23d.To the best of my knowledge, death occurred at the lime, date and place $ w 24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />�' M
<br />and due to the cause(s) stated. (Signature
<br />and Title) V p the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />°F
<br />-� n 12 a0
<br />25. DIDTOBACCO USE CONTRIBUTETD HE DEATH?
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />261b. WAS CONSENT GRANTED?
<br />U YES NO ❑PROBABLY
<br />-,-.�.-. ____.
<br />❑UNKNOWN
<br />❑ YESfJD
<br />No( Applicable If 28a Is NO U YES U NO
<br />_...........
<br />27. NAME, TITLE AND
<br />DADpRESSOFCERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type crPrint)
<br />M.A. Tompkins, M.D.,
<br />Grand Island Veterans Han 6$$03
<br />28a. REGISTRAR'S SIGNATURE
<br />A.
<br />281b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />LIAR 15 2005
<br />4 0
<br />
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