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<br />
<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 REt;QRD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT~, WHICH IS
<br />
<br />:::;::~~:::::;TORY FOR VITAL RECORDS. ..~~~:l~~~
<br />6 ~LEYs1ewPER
<br />~~~L~. NE~~~~KA 20071039 7 ~;::~J;r~~
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVId!&EINANCE AN~
<br />CERTIFICATE OF DEATH-'-"""~-'-co,""
<br />
<br />;r
<br />
<br />277J3
<br />
<br />1
<br />
<br />1, DECEDENT'S.NAME (First,
<br />Robert
<br />
<br />Middle,
<br />William
<br />
<br />Last,
<br />Ed ar
<br />
<br />Suffix)
<br />
<br />2 SEX
<br />
<br />Male
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr.)
<br />Jul 16, 200,!_
<br />6, DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />4. CiTY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Iowa
<br />
<br />Sa. AGE-Last Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />79
<br />
<br />October 12, 1927_
<br />
<br />7 SOCIAL SECU~ITY NUMBE;-- -- 3- B;-PLACE OF DEATH
<br />4 8 4 - 28 - 0 0 9 0 !::IQSElIAJ..
<br />FACILlTY.NAME (If not Institution, give streat and number)
<br />
<br />4233 New York Ave.
<br />
<br />o Inpalient
<br />
<br />Qll:IEB:
<br />
<br />o Nursing Home/LTC 0 Hospice Facility
<br />
<br />o ER/Oulpatiant
<br />
<br />IX Decedent'. Homo
<br />
<br />OCO\
<br />
<br />o Other (Spocify)
<br />
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island.
<br />
<br />68803
<br />
<br />--~] 9b.C::; I
<br />
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />9f ZIP CODE
<br />68803
<br />
<br />9g. INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />4233 New York Ave.
<br />-lOa. MARITAL STATUS AT TIME OF DEATH--~ Married 0 Never Married
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, Lest, Suffix) If wife, give maiden name.
<br />
<br />ried, but .eperatad 0 Widowed 0 Divorced 1:1 Unknown
<br />
<br />Margaret Long
<br />
<br />11. FATHER'S.NAME (First,
<br />Lloyd
<br />
<br />Middle,
<br />
<br />M.
<br />
<br />Last,
<br />Edgar
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (First,
<br />Helena
<br />
<br />Middle, Malden Surname)
<br />Reid
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates of .ervice if yes. t4e.INFORMANT-NAME
<br />~~~,orun~)9/19L4_6-2/2~./48 Margaret Edgar
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />15. METHOD OF OISPOSITION
<br />o Burial 0 Donation
<br />~Cremation 0 Entombmenl
<br />
<br />16a. EMBALMER-SIGNATURE
<br />Not embalmed
<br />
<br />16b. LICENSE NO.
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY ITOWN
<br />
<br />16c. DATE (MO., D.y, Yr. )
<br />July 17, 29_07
<br />STATE
<br />
<br />1:1 Remov.1 0 Olher (Specify)
<br />
<br />Central Nebraska Cremation Service, Gibbon, Nebraska
<br />
<br />- .
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, St.te)
<br />
<br />PART I. Enter the ~~--diseases, injuries, Or complica1ions--thal directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiretory .rresl, or venfricular fibrillation wilhout Showing the etiology. DO NOT ABBREVIATE. Enler only one c.use on a line. Add additional lines If necess.ry.
<br />
<br />::MEDIA~ J ~,'
<br />
<br />
<br />DUE TO, ORASACONSE~
<br />
<br />~~ ~.d\
<br />1>
<br />
<br />~
<br />
<br />IMMEDIATE CAUSE (Final
<br />di...... o'condltlon ....ulting
<br />In death)
<br />
<br />S.quentlelly list condition., II
<br />any, leading to the CBuBslIsted
<br />on line a.
<br />Ent..the UNDERLYING CAUSE
<br />(dl..... Or Injury th.t Initiated
<br />the ev.nts ,ooultlng In death)
<br />LAS!"
<br />
<br />(b)
<br />
<br />..~ . ,,-
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />onsello de.th
<br />
<br />(c)
<br />
<br />""- "--
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsello death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions comributing to tha d.ath but not resulting in the underlying cause given in PART I.
<br />
<br />~~ ~'-
<br />
<br />o Not pregnant, bul pregnanl43 days to 1 year bafore dealh
<br />o Unknown if pregnant Within the past year
<br />22a DATE OF INJURY (Mo, Day, Yr) ] 22b TIME OF INJUR:
<br />
<br />22d INJURY ATWDAK?T2e DESCRIBE HOW INJURY OCCURRED
<br />o YES 0 NO
<br />- -.
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT NO,
<br />
<br />o Suicide 0 Could nol be determined
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />o PedasUian
<br />
<br />o Other (Specify)
<br />
<br />1 g. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES ~NO_...
<br />21<. WAS AN AUTOPSY PERFORMED?
<br />
<br />
<br />20. IF FEMALE;
<br />o N'ot pregnanl within p.sl year
<br />o Pregnant at time of death
<br />o Not pregnant, but pregnant within 42 days of death
<br />
<br />21a.~NNER OF DEATH
<br />.){ N.tural 0 Homicide
<br />
<br />o AccidentO Pending Investigation
<br />
<br />o YES
<br />
<br />~O
<br />
<br />21d. WERE AUTOPSY FiNDINGS AVAILASLETO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />22c PLACE OF INJURY-At homa, farm, streel, f.ctory, office building, conatrucllon site, etc (Spaclty)
<br />
<br />CITYIfOWN
<br />
<br />STI>JE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo , Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23d. To the best of m knowledg ,death occurred at the time, date and place
<br />and due 10 Ihe causels) stated. (Signature and Title) "
<br />
<br />
<br />230. TIME OF DEATH
<br />2 : 05 a.m.
<br />
<br />,..~~
<br />.QuZ
<br />_a:
<br />l~~!j
<br />!i~i=25
<br />"wZ
<br />.8i~
<br />~rr-
<br />
<br />m
<br />
<br />.J.uly 16.t-
<br />23b. DATE SIGNED I
<br />..,
<br />
<br />24C. PRONOUNCED DEAD (Mo., D.y, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />W0"'
<br />
<br />
<br />24e. On the basis of examination and/or invesligatlo~. in _r:':':l..9E!DlO!l d~ Occurred at
<br />. tl'....1I..., ".t..nd'plaC.'am:tauo ioth~ase(a) atat.d. (Signeture and Tltie) "
<br />
<br />25. DIDTOBACCOUSECONTRIBUTETOTHE DEATH? 26.. HAS ORGAN ORTISSUE DONATION BEEN CONSIDERED?
<br />
<br />~ES 0 NO 0 PROBABLY 0 UNKNOWN 0 YES . ~O
<br />27. ME, TITLE AND ADDRESS CiF"ciEiHlFIER (PHYSICIAN, CORONER~S PHYSICIAN OiiCOUNTY ATTOm~'EY) (Type or Prinl)'--
<br />William Landis M.D., 2444 W. F idley Ave., Grand
<br />
<br />2Sb. WAS CONSENT GRANTED?
<br />
<br />Not Aeplic.ble if 26a Is N~ 0 YES 0 NO
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />
<br />Island, Nebraska 6880
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />JUL 1 9 2007
<br />
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