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<br />STATE OF NEBRASKA
<br />
<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 R~FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSJit'eS/SliJjfiJ2~jjICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . A!f;j):f!.::':o~~ '
<br />
<br />
<br />~~7~~;~E 200606657 t~r~~~~3~:~
<br />
<br />LINCOLN, NEBRASKA HE{ti.t;(~N.IlHUMAi'J~~k#~i#ES
<br />
<br />. ._"--
<br />
<br />
<br />. '_,,:', ~,~~-i.:, -- .-:.
<br />
<br />-- -- ,=-:::':::::. . ,';"--\
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE'ANl'> SUPPORt:"".,.
<br />
<br />CERI.LFtGATE OF DEATH . .,. -. .2387
<br />
<br />1. DECEDENT'S.NAME (Fltst.
<br />Robert
<br />
<br />Middle,
<br />Russell
<br />
<br />Last,
<br />
<br />Cramer
<br />
<br />Sulflx)
<br />
<br />2. SEX
<br />Male
<br />
<br />3.DATE OF DEATH (Mo.. Day. Yr.)
<br />November 4, 2005
<br />
<br />.I 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 61RTH
<br />
<br />Marcus, Washi~~~~
<br />7. SOCIAL SECURITY NUMBER
<br />706-07-3927
<br />
<br />Sa. AGE.LastBlrthdsy 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />88
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo.. Day. Yr.)
<br />
<br />April 25, 1917
<br />
<br />8a. PLACE OF DEATH
<br />1i0SPJTAl:
<br />
<br />o Inpalient
<br />
<br />QItiEB: ~ Nursing Home/LTC W Hospice Faclllly
<br />
<br />8b. FACILlTY.NAME (If not institution, give str.at and number)
<br />
<br />o ER/Oulpatient
<br />
<br />o Decedant's Homa
<br />
<br />Center
<br />
<br />Ot:O\
<br />
<br />o .olhar (Specify)
<br />
<br />ad. COUNTY OF DEATH
<br />Hall
<br />
<br />24J._. SO_1,1J:.h Vine
<br />
<br />
<br />gUlP CODE
<br />68801
<br />
<br />gg. INSIDE CITY LIMITS
<br />
<br />QIl YES U NO
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH W Married 0 Never Married lOb. NAME OF SPOUSE (Flrsl. Middle. Last, Sulllx) If wife. give maiden name.
<br />
<br />o Married, bUI separsted KI Widowed 0 Divorced 0 Unknown
<br />
<br />11. FATHER'S.NAME (Flrsl,
<br />
<br />Middle.
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (Fltst,
<br />
<br />~~_4AL..
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />~cremallon 0 Enlombment
<br />o Removal 0 Othar (Specify)
<br />
<br />CITY / TOWN
<br />
<br />Applequist
<br />14b. RELATIONSHIP TO DECEDENT
<br />p.a ugh t e r
<br />16c. DATE (Mo., Day, Yr.)
<br />N ovembeI..2 L 2005
<br />STATE
<br />
<br />Wi 1.1J 8,IILRus.!3 e 11 C r ame r
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates of sarvlcalf yes. 14a.INFORMANT.NAME
<br />(.xs~$.or unk.) 5 / 5 / 6 3 - 5 / 3 1 / 6 6 C h a r lot t e P raw I
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />OSurlat
<br />
<br />o Donallon
<br />
<br />16e. EMBALMER. SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />16b. LICENSE NO.
<br />
<br />Central Nebraska Cremation Service
<br />
<br />Grand Island, NE
<br />
<br />PART I. Enter the chain,pllli,!ill11..diseasBs, Injuries, or complicallonsu\hat dIrectly caused the dealh. DO NOT enter terminalevants such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the ellology. DO NOT ABBREVIATE. Enter only on8 cause on a line. Add addilionallinBs if necessary.
<br />
<br />IMMEDiATE CAUSE:
<br />
<br />onset 10 death
<br />
<br />IMMEDIATE CAUSE (Flna'
<br />dl....se or condlllon resulting
<br />In d.alh)
<br />
<br />Sequenllallyllslcondlllons,1I (b) .. r::O~M 'f
<br />eny, leedlnglo the caua.llsled -iiu'E'i-Q;'OR 'AS' A CONSEQUENCE OF:
<br />on line a.
<br />Enterlhe UNDERLYING CAUSE
<br />(disease or Injury Ihallnlllaled (c)
<br />Ihe avenla reaulllng In death) -[iUETM'ii';;;S' A CONSEQUENCE OF:
<br />lAST
<br />
<br />(a) (lAIC./) ,4-<:
<br />DU~ TO, OR AS A CONS~QUENCEOF:
<br />
<br />S" u /J/J vJ r::?["..p1
<br />~~"."' ~., ." -"". ...- -,..,
<br />
<br />S /Y1 {~
<br />
<br />onsello death
<br />
<br />M-/M y ;J r J t.4- S L
<br />
<br />s-YN
<br />
<br />onset 10 death
<br />
<br />onsat 10 death
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.Condillons contribuling to Ihe dealh bul not ra.ulllng In the underlying cause given in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />W YES
<br />
<br />o NO
<br />
<br />20. IF FEMALE:
<br />o Not pragnant within past year
<br />o Pregnanl al lime of de.ath
<br />o Not pregnant, but pragnant within 42 deys of death
<br />o NOI pregnant, but pregnant 43 days 10 1 yeer before dealh
<br />Q Unknown If pregnant within the past year
<br />
<br />21a. MANNER OF DEATH
<br />~atural 0 Homicide
<br />
<br />o AccidenlO Panding Investigallon
<br />
<br />W Suicide 0 Could nol be determined
<br />
<br />21 b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />U Drlvar/Operalor
<br />
<br />o Passenger
<br />LJ Pad.strlan
<br />o Other (Specify)
<br />
<br />DYES
<br />
<br />940
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />DYES 0 NO
<br />
<br />
<br />22a. DATE OF INJURY (Mo., Day. Yr.)
<br />
<br />22b. TIME OF INJURY 220. PLACE OF INJURY.AI home, farm. street. factory, olllce building, construction .ite. elc. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCAl'ION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Dey, Yr.)
<br />
<br />24a. DATE SIGNED (Mo., Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />am
<br />
<br />Z)-
<br />.....: uJ
<br />.o2~
<br />""'2
<br />">1=;
<br />U..:~
<br />gni!i
<br />"wZ
<br />.,z::>
<br />.coo
<br />~a:U
<br />8 I;
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24a. On Ih. basis of ax ami nation and/or Invasllgation, In my opinion daalh occurrad al
<br />thalima, data and place and dualo tha cau.a(s) slaled. (Signatura and Tllla) T
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />NO 0 PR06A~~Y 0 UNKNOWN 0 YES...,~~__._.__
<br />AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />
<br />26b. WAS CONSENT GRANTED?
<br />,N~~.!'~~~~~f.28.is N\? 0 YES~O
<br />
<br />NE 68803
<br />
<br />~
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day. Yr.)
<br />
<br />NOV .=. B 2005
<br />
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