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<br />... . <br /> <br />1. DECEDENT - NAME <br /> <br />;' ...-:. <br />WHEN THIS Copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH ANfI'Hf1WIAN .SERVlCES <br />SYSTEM, "CERnFIES THE BELOW TO fIE A TRUE COPY OF THE ORIGINAL--RiY:;oRf)fDNFILE WITH <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA DSTtCS'SEcTlOil,WHICH IS <br />THE LEGAL DEPOSITORY.FORvtfAL RECORDS. ~": :~f.--~--~J~= --WJ3- ';~-.-~ <br />.. .. 'W <br />DATE OF ISSUANCE . _ - -= ~ -= -:: -'0 <br />5/2/2003 20080213 7 A~~STA~T:~~;=~: <br />LINCOLN, NEBRASKA HEALTH ANtiHOtMfII-,-uJMtJES. $'t'_M' <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMANSERVIct~FlNANfWANifSUPPORT <br />VITALSTATISnCS '-..'~:""." '-~~, '. '0" 3 <br />CERTIFICATE OF DEATIi'->:;.--~/:;:c;;(" . <br /> <br />MOffet~:~_ 12. ::le rJ::;:O:T~;:nlh;'~~~; <br /> <br />5a. AGE. - Last Birthday uNDER 1 YEAR 6. DATE OF BIRiH (Month. Day. Y~rJ <br />IY".j Sb. MOS. I DAYS <br />66 I <br /> <br />04805 <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />Robert <br /> <br />Gene <br /> <br />4. CITY AND STArE OF BIRTH lit nDtin U.S.A.. r'1am~ cotJntry) <br /> <br />Gibbon, __N_ebraska <br />7. SOCIAL SECURTIY NUMBER <br /> <br />Ba. PLACE OF DEATH <br /> <br /> <br />October 7 <br /> <br />1936 <br /> <br />Bb. FACILITY. Name <br /> <br />(If not institution. give street and number) <br /> <br />HOSPITAL: 0 Inpatient <br />o ER Outpatient <br />o DOA <br /> <br />OTHER: 0 Nursing Home <br /> <br />~ Residence <br /> <br />o Other {SpeclfYI <br /> <br />505-52-1269 <br /> <br />10712 W. Wood River Rd. <br />Be. CITY. TOWN OR LOCATION OF DEATH <br /> <br />Wood River <br /> <br /> <br />Bd. INSIDE CITY LIMITS <br /> <br />---,~y....D~ <br /> <br />crry, TOWN QR !...OC.~:IO~J <br />Wood River <br />NCBl'tit3kti <br /> <br />Be. COUNTY OF DEATH <br /> <br />14a. uSuAL OCCUPATION (Giv8 kind of work dOrJ9 during most <br />01 working life. eVfJfJ If retirei;!) <br />Farmer <br /> <br />American <br />14b. <br /> <br /> <br />lI",lo-l--- ---.,- <br />ETRE"T MID NUMGE8 ,-"'",ud,',. '6'8'8'8 j <br /> <br />Wood River Rd. <br /> <br />~~~~......._~-: ")1'._ <br /> <br />9r1o FlE'.c:H)E'N(;F: - ~rATE: <br /> <br />9h C01.INTY <br /> <br />...1.__Hall <br />10. RACE -Ie.g., White. aUu;k, American Indian. 11, ANCES'iRY (e.g. <br />ete.jISpecify! Wh i t e (Specifyl <br /> <br />~~. 1~.jSIGr:;; CiTY LiMll~ <br /> <br />Nebraska <br /> <br />Yes D NO IKJ <br /> <br />Italian, Mexican. German, etc) <br /> <br />13. NAME OF S~OUSE (If wif8. give maid8r'l t'lam6) <br /> <br />Deniece Dellert <br /> <br />lB. FATHER - NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />Agriculture <br />LAST 17 MOTHER <br /> <br />15. EDUCATION (Specify only highsS1 grade comple1ed) <br />Elementarf; or Secondary (0-12) I College (1-4 or 5;.-) <br />12tn Grade ' <br />MIDDLE MAIDEN SURNAME <br /> <br /> <br />Robert Moffett Helen <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? . 10/14/195 <br />(II yes, give war and dates of S9N1C9:!'il <br />Korean Con. -10/13/1957 Deniece Moffett <br />MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIPI <br /> <br />McTavish <br /> <br /> <br />Nebraska_Q{3~83_._ <br />21.. METHOD OF DISPOSITION 21b. DATE <br /> <br />21c. CEMETERY OR CREMATORY. NAME <br /> <br />[K] Burial <br /> <br />D Removal A r. 30, 2003 Ft. <br />21 d. CEMETERY OR CREMATORY LOCA nON <br /> <br />McPherson National Cern <br />CITY OR TOWN STATE <br /> <br />Liv1ngston-Sondermann F.H. <br />22b. FUNERAL HOME ADDRESS ISTREET OFfFi.F.'D. NO. CITY OR TOWN. STATE. ziPI <br /> <br />D Cremation 0 Donation <br /> <br />Maxwell, Nebraska <br /> <br />601 N. Webb Road, Grand Island, Nebraska 68803-4050 <br /> <br />~~R::MMED~E~~C- .. VJ&pIt;:;;~Ec~~I.ANDlell <br /> <br />DUE TO. OR AS A CONSEQUENCE OF. r - . <br /> <br />Ye. <br /> <br />I <br />I <br />IK <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />25. WAS CASE REFERRED TO MEDICAL <br />~XAMINER OR CORONER? <br />Yes D,_....,.~9._0 <br />) <br /> <br />Interval between onset and death <br /> <br />Interval between onset and death <br /> <br />7 MOk~-; <br /> <br />Ib) <br />DuE TO. OR AS A CONSEQUENCE OF. <br /> <br />Interval between onset and death <br /> <br />lei <br /> <br />OTHE:R SIGNIFICANT CONOITIONS - Conditions contributing 10 the death but riot related <br /> <br />PART ~ I ..tl A J d <br />II V\--()"""' ~ <br /> <br />1260:------- . <br />: 0 Accident 0 Undetermined <br />o Suicide D Pending <br />o Homicide Investigation <br /> <br />2Bb. DATE OF INJURY <br /> <br /> <br />HOUR OF INJURY <br /> <br />PART III IF FEMALE. WAS THERE A <br />PREGNANCY It'! THE PAST 3 MONTHS? <br /> <br />(Ages 10-54) Yes D.. No 0 <br />2Bd. DESCRIBE HOW INJURY OCCURRED <br /> <br />24. AUTOPSY <br /> <br />o No ..f:sd <br /> <br />26.. INJURY AT WORK <br />Yes 0 NO 0 <br /> <br />2Bg. LOCATION <br /> <br />STREET OR R.F.D. NO. <br /> <br />CITY OR TOWN STATE <br /> <br />21a. <br /> <br />DATE OF DEATH (Mo.. Day y,) <br /> <br />t./ ~ ;2-;-' O?3 <br /> <br />DATE SIGNED (Mo.. Day. Y,.! <br /> <br />tj~J.rc~o3 <br /> <br />28.. DATE SIGNED (Mo.. Day. Yr.) <br /> <br />2Bb. TIME OF DEATH <br /> <br />l;~ .+ <br />i li 27b. <br />~;;;,.. <br />8 '8-g ,-\- <br />J'l'E <br />~~ <br /> <br /> <br />z,. <br />~:5;~ <br />I ~ ~,. 2Be. PRONOUNCED DEAD (Mo.. Day, Yr.) 2Bd. PRONOUNCED OEAD (Hou'l <br /> <br />8",~g <br />M J'l ~ ~ <br />~ a: 8 28e, On the basis of examination and/Or Investigation, In my opinion death occurred at <br />8 <:i ~"_ the time. date and place and due to the cause(slstated. <br /> <br />. Si nature and Title <br />.. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED? 30.b WAS CONSENT GRANTED? <br /> <br />M <br /> <br />M <br /> <br />29. <br /> <br />k- <br /> <br />DYES <br /> <br />-RJ NO <br /> <br />x- <br /> <br />DYES <br /> <br />~ NO <br /> <br />:~~D~E;dCE~rE~CIAN. CORON~RS PHYS~-~ OR COuNTY ATTORNEY! ----- <br /> <br /> <br />32a. REGISTRAR ..- - . <br /> <br />