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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES <br />SYSTEM, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL Rt;J?9RP,~~~FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL SrAnl!~~W!"ICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . '~~---=~~':;;-:' ~'J/?!,;2" <br /> <br />DATEDFmSUANCE M~~~R <br />3/29/2004 20060655 9 ASSlSTA/p,~~RfG'$TRAR <br />LINCOLN, NEBRASKA HEAL TH ANp~MjfN~~:~~c:~,,~t~J~M <br /> <br />STATEOFNEBRASKA-DEPARTMENTOFHEAL1HANDHUMAN~~~~'St$ioRr 03434 <br />VITAL STATISTICS ,., - - ".. 'c. '^. , ".,,"'.. ..-' 0 4 <br />CERTlFICATEOFDEAlH ,~".~"'-"~._\. _-",0- .' <br />1~ OEcmENT-NAME FIRST MIDDLE LAST 2, SEX 3. DATE OF DEATH (Month-Day. YB8J') <br /> <br />Robert <br />4. CITY AND STATE OF BIRTH IKnot.. U.S-A.. """'" coonIry} <br /> <br />_ Grand Island, Nebraska <br />"'!! 7. SOCiACSECURTI'{NUMBER <br />-. <br />J 508-18-7682 <br />; 8b. FACILITY. N...,.. /If not 1'-', give _I ana numbsr} <br />~. <br />~ St. Francis Skilled Care Nurs~ng <br />. &:. CITY. TOWN' OR LOCATION OF DEATH <br /> <br /> <br />r 2 1923 <br /> <br />Leslie <br />UNDER 1 YEAR <br />Sb. MOS. DAYS <br /> <br />Male <br />. UNDER 1 DAY <br />5e. HOURS 1 .. MINS, <br />, <br /> <br />Mar 20 2004 <br />6. DATE OF BIRTH IMonth. Day. Y..,} <br /> <br />Inpatient OTHER, ~ Nursing HOme <br />ER'OUll>a\ieot [] Residence <br />DOA 0 Other ISpeC"YI <br /> <br />Grand Island <br />98. RESIDENCE - STATE <br /> <br />Nebraska <br />1~. RACE ~ (e.g., Whl~. Btac:k. AlMfiean Indian. <br />""'.1181>0<:'1)'1 <br /> <br />9d STREET AND NUMBER I'nc'-.g ZIp~} ge. INSIDE CITY LIMITS <br />68801 vesOO No.D <br />13. NAMEOFSPOUSE Ilfwife. givemaidenmi"",} <br /> <br />MAIDEN SURNAME <br /> <br />Catherine Clara Bixenmann <br /> <br /> <br />Island <br /> <br />/ C )92 <br /> <br />NE 68801 <br />21a MfTHOOOfotSPOsmON 21b. DATE <br /> <br />210. C~MET~RYOR CREMATORY - NAME <br /> <br />~BUriaJ o Re;"Q'" Mar 23, 2004 <br /> <br />Grand Island City <br /> <br />21d. C~M~ERY OR CREMATORY LOCATION <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />Curran Funeral Cha el <br />22b. FUNERAL HOME ADDRESS (STREET ORA.F.O: NO.. CITY OR TOWN. STATE. ZlPl <br /> <br />o Cramarlon 0 Dooallon <br /> <br />3168 W. Stolle <br /> <br />Park Rd. Grand Island NE <br /> <br />3005 South Locust Street <br />211~ IMMEDIATE CAUSE. <br />r.. PART C <br />I I 101 c("\. S. . <br />11 DUE TO. OR AS A OONSEOUENCE OF; <br />41 <br />]llbl <br />DUE TO. OR iis-,"-CONSEQUENCE b( <br /> <br /> <br />Grand Island NE 68801 <br />IENTER ONL v ONE CAUSE pER L~NE FOR 1.1. Ibl, AND loll <br /> <br />Interval between onsal and dea1h <br /> <br />Interval between onset and death <br /> <br />I Interval between onset and death <br />I <br />I <br />I <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br /> <br /> <br />260. <br />D Accidenl 0 Uncletem'linlKl <br />o Suioide 0 Pondirlg <br />D Homicide InY8$tSgMon <br /> <br />28b, DATE OF INUURY IMo. Oay.. Yr.) 26<. HOU.R OF INUURY <br /> <br /> <br />26g. LOCATION <br /> <br />'STREET OR RF.D. NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />.~ ISi ~ <br />- fO <br />: .!l~ <br />i~ <br />J <br /> <br /> <br />260. INUURY AT WORK <br />v..D NoD <br /> <br />2 . DATE OF DEATH IM<J.. Oay.. Yr.} <br /> <br />.~ ()..A. '2---C) <br /> <br />IO~ <br /> <br />280. DATE SIGNED IMo.. Oay.. Y,.} <br /> <br />28b. TIME OF DEAT'" <br /> <br />m <br /> <br />....~ (u <br />ID~~ <br />I>=>- <br />,,<(~ <br />t;?id'5 <br />'.8 ~ ~ <br />~i8 <br />8 " <br /> <br />M <br /> <br />280. PRONOUNCED DEAD IMo.. Day., Yr.} <br /> <br />28d. PRONOUNCED DEAD IHou,} <br /> <br />M <br /> <br />M <br /> <br />2&8. On the basis Of examination anI1lOlInIJ9Stigatlon. In my opinion death OCCLlITed at <br />the time, date and ~ce and due to ttliI cause(s) stated. <br /> <br />:J9.lt WAS CONSENT GRANTED? <br />o YES ~.. <br /> <br />Tariq Mubin M.D. <br />32a REGISTRAR, <br /> <br /> <br />Grand Island NE <br /> <br />68803 <br />32b. OA TE FIL~D BY ReGISTRAR IMo.. Day. Yr.! <br /> <br />MAR 2 S 2004 <br />