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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REVD LILON�f:WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT1$TJe-%- -$WkW- fE'�kl V IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE A APR 2 0 2006 200604276 STATER COOPER S AS3ISTANI` STATE REOI$MA#fi LINCOLN, NEBRASKA HEALT 4 ANJ7 NUMAN._SERVICES STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOFn, C CERTIFICATE 0F. DEATH �1 1. DECEDENT'S -NAME (FIrs1, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.) Robert William Gloe Male March 30, 2006 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 8a. AGE -Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) MOS. DAYS HOURS MINS. Wood River, Nebraska 72 February 4, 1934 7. SOCIAL SECURITY NUMBER 506- 4+14 =3880 - �'!iirt 8b. FACILITY -NAME (II not Institution give street and number) 2.4 32.4 8a. PLACE OF DEATH . - i4ospiTAi: Cllff�afitlrlr a ��w(ftHom.�LTC Q U ER /Outpatient ® Decedent's Home 5363 So 110th Road Q DC O Other (Specify) 8c. CITY CITY OR T - Zip Code) .. OWN OF DEATH (Include Zip Bd. COUNTY OF DEATH Wood River Hall 9e, RESIDENCE -STATE 9b. COUNTY 9c. CITY OR TOWN Nebraska Hall Wood River 9d, STREET AND NUMBER 9e. ZIP CODE 9g. INSIDE CITY LIMITS 5363 S. 110th Road �� 68883 ❑YES NO APT. NO 9f. 10a. MARITAL STATUS AT TIME OF DEATHXELMarded ❑ Never Married I10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. ❑ Married, but separated ❑ Widowed D Divorced ❑ unknown Mary Elizabeth Whitaker 11. FATHER'S•NAME (First, Middle, Last, S=fflx)12. R'S -NAM E (First, Y Middle, Maiden Surname) Herman J. Gloe Martha E. Sick 13, EVER IN U.S. ARMED FORCES? Give dates of service it yes. 14a. IN• FORMANT•NAME 144. RELATIONSHIP TO DECEDENT (Yes, no, or ui es Jan 14, 1966 Mar 2, 1955 Mary Gloe wife 15. METHOD OF DISPOSITION 16a. EMBALM - SIGNATURE t /O 18b. LICENSE N0. 16c. DATE (MO., bay, Yr,) %Burlal L) Donation 7 A�1rll 3, 2006 ❑ Cremation ❑ Entombment 16d. CEMETERY, OFIEMAT69 OR O HER LOCATION CITY / TOWN STATE D Removal ❑ Other (Specify) Grand Island City Cemetery Grand Island Nebraska m_^ 17a. FUNERAL HOME NAME ANA MAILING ADDRESS (Street, City or Town, State) 174. Zip Code Apfel Funeral Home 411: West 11th.St. PXII.Aim 126 Waqd r+46I a*k& . +.. 18. PART I, Enter the ghjp of events.- diseases, injuries, or complications --that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL I respiratory arrest, or ventricular fibrillation without showing the etlology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. I IMMEDIATECAUSE: onset to death I immediate I onset to death I I I onset to death I onsettodealh I 18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ET YES Q NO 20. IF FEMALE: 21a.MANNEROF DEATH 21b. IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? 13 Natural ❑ Homicide ❑ Driver /Operator U Not pregnant within past year ❑YES �l NO • Pregnant at time of death Q Accident❑ Pending Investigation U Passenger • Not pregnant, but pregnant within 42 days of death ®Suicide Q Could not be determined ❑ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO • Not pregnant, but pregnant 43 days to 1 year before death U Other (Specify) I COMPLETE CAUSE OF DEATH? • Unknown I! pregnant witrdn the past year ❑ YES " NO 221 DATE OF INJURY (Mo Day Yr,) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, lartery, office building, construction site, etc. ( Spenify) _March 30_1 2006 0: 50 pro m _:_•home 22d.INJURYATWORK? 22e. DESCRIBE HOW INJURY OCCURRED ,DYES &NO self- inflicted gunshot wound ;F 221. LOCATION OF INJURY - STREET 8 NUMBER, APT, NO. CITYlrOWN i. 5363 S 120 Road, Wood River 23a. DATE OF DEATH (Mo., Day, Yr.) a March 30, 2006 23b.DATESIGNED(Mo.. Day, Yr.) 23c. TIME OFDEATH m Ea, 3 00 e I M 23d. To the best of my knowledge, death occurred at the time, data and place and due to the cause(s) stated. (Signature and Title) (a) Massive Mead injury IMMEDIATE CAUSE (Final disease or condition resulting DUE TO, ORASACONSEOUENCEOF: In death) 24a. DATE SIGNED (Mo., Day, Yr,) Sequentially list conditions, If N_ n s h o t any, leading to the cause listed --gu DUE TO, OR AS A CONSEQUENCE OF: on line a. 24c. PRONOUNCED DEAD (Mo., Day, Yr.) Enter the UNDERLYING CAUSE ideas so or injury that Initlated (o) the events resulting indeath) DUE TO, OR As A CONSEQUENCE OF: LAST 0 w g o p 2 . the basis el exa inati nd/ nvestigatien, In my opinion death occurred at th time date and p and e t he causes) stated.(Signal ur Title )+r (d) I immediate I onset to death I I I onset to death I onsettodealh I 18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ET YES Q NO 20. IF FEMALE: 21a.MANNEROF DEATH 21b. IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? 13 Natural ❑ Homicide ❑ Driver /Operator U Not pregnant within past year ❑YES �l NO • Pregnant at time of death Q Accident❑ Pending Investigation U Passenger • Not pregnant, but pregnant within 42 days of death ®Suicide Q Could not be determined ❑ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO • Not pregnant, but pregnant 43 days to 1 year before death U Other (Specify) I COMPLETE CAUSE OF DEATH? • Unknown I! pregnant witrdn the past year ❑ YES " NO 221 DATE OF INJURY (Mo Day Yr,) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, lartery, office building, construction site, etc. ( Spenify) _March 30_1 2006 0: 50 pro m _:_•home 22d.INJURYATWORK? 22e. DESCRIBE HOW INJURY OCCURRED ,DYES &NO self- inflicted gunshot wound ;F 221. LOCATION OF INJURY - STREET 8 NUMBER, APT, NO. CITYlrOWN i. 5363 S 120 Road, Wood River 23a. DATE OF DEATH (Mo., Day, Yr.) a March 30, 2006 23b.DATESIGNED(Mo.. Day, Yr.) 23c. TIME OFDEATH m Ea, 3 00 e I M 23d. To the best of my knowledge, death occurred at the time, data and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 268. HAS ORGAN OR TISSUE DONATION BEEN CONSI ❑ YES �] NO ❑ PROBABLY ❑ UNKNOWN U YES FSl NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prid, Michelle J Oldham Chef De ut n 28a. REGISTRAR'S SIGNATURE I f L � - DEFIED? I 26b, WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES Gil NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) APR 19 2006 PI sland STATE ZIPCODE NE 68883 24a. DATE SIGNED (Mo., Day, Yr,) 24b.TIME OF DEATH �! April 14, 2006 10 :50 pm m a a 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD Marc h....30,,, 06 11:40 pm m E = 0 w g o p 2 . the basis el exa inati nd/ nvestigatien, In my opinion death occurred at th time date and p and e t he causes) stated.(Signal ur Title )+r L) `o 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 268. HAS ORGAN OR TISSUE DONATION BEEN CONSI ❑ YES �] NO ❑ PROBABLY ❑ UNKNOWN U YES FSl NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prid, Michelle J Oldham Chef De ut n 28a. REGISTRAR'S SIGNATURE I f L � - DEFIED? I 26b, WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES Gil NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) APR 19 2006 PI sland