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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 ORIGINA!-B~CQR(lJ?N FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAJ...J!jtI~~J;,E~,_t,VHICH IS
<br />
<br />:~::~:U7:C:TORY FOR VITAL RECORDS. ;~~~ER
<br />AUG 0 2 2005 ~ ASSlsrAN'pSTATERtGlSctRAR
<br />LINCOLN, NEBRASKA 2 0 0 6 11 2 4 4: 1:IEAf:{,! ~!'ID H'}MAtf'SE1}VICES
<br />
<br />
<br />~
<br />
<br />..~ ~ - "-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAKlGEANnSY!'?eR""TO 5 0._8_ 2...,1_ 7___.__
<br />__ ..... .. CERTIFIC~~E_ OF DEATH______ -- - _ _ _
<br />1. DECEDENT'S-NAME (Flrsl, Middle, Last, Suffix) 2. SEX 3_ DATE OF DEATH (Mo" Dey, Yr.)
<br />Robert FredE)rick Mooch r1all';! Jul c..22_,2005
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE-Lest Birthday 5b, UNDER 1 YEAR 5c_ UNDER 1 DAY 6, DATE OF BIRTH (Mo.. Day, Yr.)
<br />Illinois (Yrs) 89 ~'-OS rDA~S HOURS MINS May 29, 1916
<br />
<br />
<br />
<br />=Laa PLACE OF DEATH
<br />
<br />___________ ,______ __________._ lillSPlTAL 0 Inpatienl QlliEfJ: MI Nursing HomelLTC W Hospice Facility
<br />
<br />
<br />Bb. FACILITY. NAME (If not Institution, give stroet end number) 0 ER/Oulpatienl 0 Decedenrs Homo
<br />
<br />
<br />
<br />o 00i\ 0 Other (Specify)
<br />Bd. COUNTY OF DEATH
<br />
<br />Grand Island
<br />
<br />.-.-=r..-...-----
<br />9b. COUNTY
<br />Hall
<br />- ,_ ,,~.__, ""., .__ _'U_.'_"',',__
<br />
<br />
<br />Hall COoot
<br />
<br />Island
<br />
<br />St. ,
<br />lOa. MARITAL STATUS ATTIME OF DEATH OlMarried 0 Never Married
<br />
<br />gUlP CODE
<br />68801
<br />
<br />-]
<br />
<br />gg_ INSIDE CITY LIMITS
<br />XI YES 0 NO
<br />
<br />10b_ NAME OF SPOUSE (First. Middle, Lasl, SUffl') II wife, give maiden name.
<br />
<br />o Married, bUI separaled 0 Widowed 0 Divoroed W Unknown
<br />
<br />Mary Bell
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />SUfll')
<br />
<br />12_ MOTHER'S-NAME (First,
<br />Alma
<br />
<br />Middle,
<br />
<br />Melden Surname)
<br />Kundert
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />wife
<br />
<br />16b. LICENSE NO_
<br />
<br />I a0t6
<br />
<br />o Cremation 0 Entombmenl
<br />
<br />CITY /TOWN
<br />Grand Island
<br />
<br />160. DATE (Mo_, Day, Yr.)
<br />Ju1)1' 26 , 2005
<br />STATE
<br />Nebraska
<br />
<br />o Rcmoval 0 Ot~er (Speolfy)
<br />
<br />om __.... _
<br />17a. FUNERAL HOME NAME AND MAltiNG ADDRESS (Street, City or Town, Stete)
<br />All Faiths Funeral Home, 2929 S. Locust St.,Grand Island, NE
<br />
<br />PART l. Enter the cha.ln_.pL~~..dlseases, InJuries, or compllcationsnthat dIrectly caused Ihe death. DO NOT enter termInal events such as cardiac arrest,
<br />respiralory errest, or ventricular fibrillation without showing Ihe etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add additional lines If necessary.
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset 10 dealh
<br />
<br />IMMEDIATE CAUSE (Flnat
<br />disease or condlllon resultIng
<br />In deat~)
<br />
<br />__(a) ~<::l.rdiorespiratorv fCi.i).ure
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />.( 1 h()1,1I"
<br />
<br />onsel to death
<br />
<br />SequenUally IIsl condIUon., If
<br />any! leading to 'he cause listed -
<br />on line..
<br />En",r th. UNDERLYING CAUSE
<br />(dlsea.. or Inlury that InlUet.d
<br />the events reSUlting In death)
<br />lAST
<br />
<br />(b) (::;(:mg~stive He~t.__Fclj.lure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />__ .I
<br />I
<br />I
<br />I
<br />
<br />6 mqn-t.h$
<br />onset 10 death
<br />
<br />(c) Coronary A1::_ten: Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />>:1 ear
<br />onset 10 death
<br />
<br />(d)
<br />
<br />18_ PART II. OTHER SIGNIFICANT CONDlTIONS-CondHlons contribullng 10 Ihe deaf~ but nol re,ulllng in t~e underlying cause given In PART I.
<br />Dementia, Dysphagia, A.Fib., Hypothyroidism, Type II Diabetes
<br />
<br />Melli tus, CA of Prostate, Inappropriate ADH Syndrane, Edema
<br />
<br />20. IF FEMALE:
<br />o Not pregnanl wll~ln pa,t year
<br />o Pregnanl alllme of deat~
<br />o Nol pregnant, bUI pregnant ';11~in 42 days 01 deal~
<br />U Not pregnant, but pregnant 43 dey' to 1 year before deat~
<br />o Unknown If pregnanl within the past year
<br />
<br />21 B. MANNER OF DEATH
<br />~ Netural U Homicide
<br />
<br />o AccidenlU Pending Invesllgation
<br />
<br />o Suicide 0 Could not be d..termlned
<br />
<br />21b, IFTRANSPORTATlON INJURY
<br />U Drlver/OperBtor
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />W Ot~er (Specify)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />U YES ~ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES ~NO
<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 />-in
<br />
<br />22a. DATE OF INJURY (Mo., Day. Yr.)
<br />
<br />22b_ TIME OF INJURY 22c, PLACE OF INJURY-AI ~ome, farm, Slreet, facto'y, olfice building, construclton sllB, etc. (Specify)
<br />
<br />22d. INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CrTYlfOWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />23,. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.1
<br />
<br />24b. TIME OF DEATH
<br />
<br />nJuly__22, 2005
<br />23b. DATE SIGNf;D (Mo" Day, Yr.)
<br />July 22, 2005
<br />
<br />23c. TIME OF DEATH
<br />4:25 A.m
<br />
<br />z>-
<br />$~!M
<br />~~~
<br />c. a.. 4:( ::;
<br />E ~UI t z
<br />8ffizo
<br />~z::>
<br />-coo
<br />,'2 a: 0
<br />o~
<br />00
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr.) 24d_ TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the best of my knowledge, death occurred at the lime, date and place
<br />and due 10 I~e causers) slaled. (Si nalure and Title) 'f
<br />
<br />Malt,...
<br />
<br />
<br />248. On the basIs of examination and/or Investigation, In my opInion death occurred at
<br />t~e lime, dale end place and due 10 Ihe causers) staled. (Signature Bnd Title) 'f
<br />
<br />25. DID TOBACCO USE CONTRIBUTE
<br />
<br />26., HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b_ WAS CONSENT GRANTED?
<br />
<br />DYES .:+J NO 0 PROBABLY 0 UNKNOWN 0 YES M NO Nol Appllceble II 26B Is NO _t.J!ES U NO
<br />27_ NAME: TITlE-AND ADDRESS OF CERTIFIER (PHysiciAN: CORONER'S PHYSICIAN OR COUNTY ATTORNEyf (Typ.-or Print)
<br />
<br />M.A. T kins 11.0. Grand Island Veterans Hane Grand Island NE 68803
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />JUL 2 6 2005
<br />
<br />2Ba_ REGISTRAR'S SIGNATURE
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