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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH. AND HUMA"'~RVlC;ES <br />SYSTEM, "CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RJ;.C;Qflf.U!.N~;W1TH" <br />THE NEBRASKA HEAL tH AND HUMAN SERVICES SYSTEM, VITAL STATI~~~,~... <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. .li!fl!J'f;Y::~)d '\ <br /> <br />DATE OF ISSUANCE 2 0 0 8 0 8 5 36' rlii~~~;js;~&~jr <br />LI~~~;,~;~~; HEALTHJ:~-=:=:I~:">' <br />"\~\ ~...!.,,-._j"gf it ". <br />STATE OF NEBRASKA- DEPARTMENT OF HEALm AND HUMANS4~s~E:~~PORT <br />VITAL STATISTICS C"~'.J'i"? ,~':' ".:..::-' ~:;i- <br />CERTIFICATE OF DEATH'''---O:.:'i..~-''-.,::;.;.,::;~ <br /> <br />. ----FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />2. SEX <br /> <br />.... <br /> <br /> <br />2003 <br /> <br />1. DECEDENT - NAME <br /> <br />Gary <br /> <br />Leo <br /> <br />Robertson <br /> <br />Male <br />UNDER 1 DA V <br />5e. HOURS' MINS. <br /> <br />6. DATE OF BIRTH (Month, Day. Veal! <br /> <br />; 4. CITY ANO SiAlE: O~ BIRTH {lfnoUn US,A., name cDuntry} <br /> <br /> <br />October 30. 1938 <br /> <br />Three Rivers. Texas <br />7. SOCIAL SECURTIV NUMBEA <br /> <br />Db. fACILITY - Name <br /> <br />(If not institution. giVtl slr8Bt and numbBr) <br /> <br />HOSPITAL: D Il1patienl OTHEA: 0 NursinQ Horne <br /> D ER Outpaijent lKJ Residence <br /> D DOA D Other (Sp9Clfvl <br /> <br />451-60-5842 <br /> <br />Horne: <br /> <br />250 N. Darr <br /> <br />Nebraska <br /> <br />Hall Grand <br /> <br /> <br />___~___._ _Hall ______ .__ <br />9d. STREET AND NUMBER {InCluding Zip Code! <br /> <br />ge. INSIDE CITY LIMITS <br /> <br />6c. CITV. TOWN OR LOCATION OF DEATH <br />Grand Island <br /> <br />'S8. RESIDENCE. STATE <br /> <br />9b. COUNTY <br /> <br />10. RAce - (e,g.. While. Biack. American Indian. <br />ole.IISp.cilvj Whi t e <br /> <br />11. ANCESTRY lo.g. <br />(Speeilyl American <br /> <br />68803 Ye. [] No D <br />1:3. NAME: OF SPOUSE (II wile, give maiden name) <br /> <br />Donna Rumley <br /> <br />14a. USUAL OCCUPATION (GiV8 kind of work don8 during most <br />of working 1118. 8vtm If fQtltsdJ <br />Heavy Equipment Operator <br />16. FATHER. NAME FIRST MIDDLE <br /> <br />Diamond Engineering <br />LAST , 7. MOTHER <br /> <br />15. EDUCATION lSpecify only highest grade complelMl <br />ElerT'4't7sec:ondar'1 /0-121 College [1-4 or 5+1 <br /> <br />MIDDLE MAIDEN SURNAME <br /> <br />Ray Lee <br />16. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />(Yo.. N ~ unk.) I Ilf Y.'. 9'v. ",.r .nd d.... of ..",rC.'j <br /> <br />19b. INFOAMANT MAILING AODRESS -- <br /> <br /> <br />Clara <br /> <br />Cerine <br /> <br />Yawn <br /> <br />Donna Robertson <br />.. -ISTREET'OR R.FD. NO__ CITY OR TOWN. STATE. ZIP) <br /> <br />250 North Darr Grand Island. Nebraska 68803 <br /> <br />20. EMBALMER - SIGNATURE & LICENSE NO. <br /> <br />21 'a~ METHOD OF DISPOSITION <br /> <br />21b. DATE 1210. CEMETe:RY OR CREMATORY NAME <br /> <br />Oct. 13. 2003 Central NE Cremation <br />21d. CEMETERY OR CREMATORY LOCATION CITV OR TOWN <br /> <br />Service <br />STATE <br /> <br />Not Embalmed <br /> <br />22.. FUNERAL HOME - NAME <br /> <br />D SutlSI D Removal <br /> <br />Apfel-Butler-Geddes gg Cr''''a1ion D Don.llon <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br /> <br />Gibbon. Nebraska <br /> <br />1123 West Second Street <br /> <br />(bJ <br />DUE TO. OR AS A CONSEQUENCE OF:" <br /> <br /> <br />Grand Island. Nebraska 68801 <br />(ENTER ONLY ONE CAUSE PER LINE FOR 1.,. Ib). AND (ciI <br /> <br />,-? "'-a -~"""""'~r <br /> <br />Inlerval belw n onset and de81h <br /> <br />23. IMMEDIATE CAUSE <br />PART <br />I 1". _ _~.e.a/ <br />DUE TO, OR AS A CON'SEOU~CE' OF' <br /> <br />~c4 <br />.-..---- <br /> <br />00;. tjJ <br /> <br />Interval berween onset a"d dealt\ <br /> <br />In1erval belwl!l@1l onset and dealh <br /> <br />(CI <br />PARr OTHER SIGNIFICANT CQNOITIONS - Condilions contributing to lhe death but not relaled <br /> <br />"CCl~CJ 7L?-<? <br /> <br />28b. DATE OF INJURY (Me.. o.y; Yr.) 26e. HOUR OF INJURY <br /> <br />26a. <br />D Accident D Undetermined <br />D SUicide D Pending <br />D HomiCide JnveslIgalion <br /> <br />26e. INJURY AT WORK <br />Yes D No 0 <br /> <br /> <br /> <br />~'" <br />~ii1 <br />H~ <br />8 ~8 <br />~1 <br />~'" <br /> <br /> <br />2B.. DATE SIGNED {Mo__ o.y. VO <br /> <br />2Bb. TIME OF DEATH <br /> <br />4 :45 p.m", <br /> <br />E~i <br />JH" <br />!~~~ <br />Bffi~ <br />~~8 <br />u" <br /> <br />M <br /> <br />27b. <br /> <br />27c. TIME OF DEATH <br /> <br />28c. PRONOUNCED DEAD (Mo__ Day. Yr.1 <br /> <br />2Bd. PRONOUNCED DEAD (Houri <br /> <br />M <br /> <br />~ee, On (he basis or examination and, or investigation. in my opinion dealh occurred at <br />the time. date and place and due to lhe c:al,lse(sl stated. <br /> <br />29. <br /> <br />M.b WAS CONSENT GRANTED? <br />DYES <br /> <br />~ <br /> <br />31. NAME AND ADDR'ESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICtAN OR COUNTY ATTORNEYI (Typo or PriM! <br /> <br />Dr. Jane <br /> <br />McDonald 800 Alpqa. Grand ~l~d. Nebraska <br /> <br />'~-A:'~ <br />. ----U ...-- <br /> <br />68803 <br /> <br />I :l2b. DATE FILED BV REOCi <br /> <br />,. <br /> <br />32.. REGISTRAA <br /> <br />{! DO" Y~003 <br />