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"~ STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT!'rr~A'N~~'/-)'OMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA.~iKA'r~AIZ~~VT O,F' HEALTH AND
<br />HUMAN SERVICES, VITAL RECQRDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR''VITA~.REt_"E7RDS~, "'
<br />I
<br />DATE OF ISSUANCE ,~~~ ~.",
<br />h~AY 2 7 2aa~ 2 0 0 9 0 5 2 7 5 , ~~I ~,~~~ ~~~I~TR~R;;
<br />,pdIR1'N1ENT OF'f9EALTH ,~{~ _ "
<br />LINCOLN, NEBRASKA _ .. F`(,IJI~' N S,Ff~VIC~~ .~ "'~
<br />~, .. s
<br />STATE OF NEBRASKA -DEPARTMENT pF HEALTH AND HUMAN 3ERVI~~B ~~'r, "•~j, ~~ ~, ~'oy~v
<br />IFICATE "~'
<br />L DECEDENTS-NAME (First, Middle, Last, Suffix) 2. SEX D . d~ATH (Mo,,Day,Yr.)
<br />" 1:.. ^ ",
<br />Jimm Lester Kam er Male Ma'1~~8', 2nb9 ,.
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ga. AGE-Last Birthday 6b. UNDER 1 YEAR 6c. UNDER 1 DAY B. PATE pF BIRTH (Mo:; Day, Yt)
<br />(Yrs.) MOS. DAYS HOURS MINS. i
<br />St. Paul, Nebraska 69 March 7, 1940
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505-52-5460 HOSPITAL: ^ In(xdlant 9SHE8: ^ Nuninq Horne/LTC ^ Hoaplcs Faculty
<br />t1b. FACILITY~NAME (IT not Inatitutlon, give street and number) ^ ERlOutpatlent ®Dacedent'a Homa
<br />^ DOA ^ Other(SpeclTy)
<br />_ 339 Hall St.
<br />tic. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />w Grand Island 68801 Hall
<br />Z 9a. RESIDENCE-STATE 8b. COUNTY 9c. CITY OR TOWN
<br />W
<br />~, Nebraska Hall Grand Island
<br />~ ed. STREET AND NUMBER 9a. APT. Np. iK. ZIP CODE 8g. INSIDE CITY LIMITS
<br />°' 68801 ®Yas ©No
<br />!= 339 Hall St.
<br />7ga. MARITAL STATUS AT TIME OP DEATH ®Msrried ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Laat, Suffix) H wife, glue maiden name.
<br />a~ ^ Married, but separated ^ Wldowad ^ Divorced ^ Unknown Rob n Lilienthal
<br />~' 11. FATHER'S-NAME (Pint, Middle, Lase Suffix) 12. MOTHER'S-NAME (First, Middle, Msldan Surname)
<br />E
<br />~pf Herman Kam er L die Luebke
<br />m 13. EVER IN U.8. ARMED FgRCE37 Giva dates of asrvlca If Yaa. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />F (Yaa,No,orUnk.) Yes 01/27/1959-01/25/1963 Rob n Kam er Wife
<br />15. METHOD OF DISPOSITION 18a. EMBALMER-SIGNATURE 16b. LICENSE NO. 15c. DATE (Mo., Day, Yr.)
<br />^Budal ^Donaaon Not Embalmed Ma 20, 2009
<br />®Crcmalen ^EMambment
<br />^Ramovel ^otneryapeclry) 18d. CEMETERY, CREMATORY OR OTHER LOCATION C17YITOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, 8tah) 17b. Zlp Coda
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH (See Instructions and exam les
<br />te. PAR71. Emer the dram wewnta -dieeeaee, In)udae, or enmpneaaotn-that dlme[ly eeu.ed rna dean. bo NO7 a,mr »rminal awnes.ueh ea wrdlae erreeq APPROXIMATE INTERVAL
<br />reaplntory ertest, ar vanWCaer aadllation without ahowlna the etlolopy. 00 NOT ABBRCVIAYE. EnNr only one Ceuae on a Ilea. Add eddldonsl Iinee a neneeery. t
<br />1
<br />IMM IATE GAUSS: ~ onset to death
<br />IMMEDIATE CAUSE (Final I
<br />dlaeaae or condition resulting a) 1 " ~
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF: ~ onaat to death
<br />Sequentlslly Ilst conditlana, R I
<br />b) t
<br />any, leading to the cause listed I
<br />on Ilne a. DUE TO, OR AS A CONSEQUENCE OF: ~ onset to death
<br />I
<br />Enter the UNDERLYING CAUSE c) ~
<br />(dlaesas or Injury that initiated ~
<br />the events rosulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to duth
<br />LAST ~
<br />I
<br />d) I
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contdbuting to the death but not roaultlng In the undadying cause given In PART I. 79, Wq8 MEDICAL EXAMINER
<br />OR CORONER CONTACTE07
<br />• ^ YES ~NO
<br />~5~~:~-I
<br />W 20. IF FEMALE: 21 s, MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORME07
<br />~ ~ot pregnant within past year~Natunl ^ Homicide ©DdvadOperetor ^ YES ~KO
<br />(~~' ^ Prognant st tlme of death ^ Accident ^ Pending Investlgatlon ^ Psaaengar 27d, WERE AUTOPSY FINDINGS AVAILABLE
<br />^ Nat pregnant, but pregnant within 42 days of death ^ Sulclda ^ Could not be determined ^ Psdestdan TO COMPLETEr~~-CA~~USE OF OEATH7
<br />^ Not pregnant, but pregnant 43 days to 1 year before death ©Othar (Specify) ^ YES ~tv0
<br />4f ^Unknown It pregnant wlthiri the peat year
<br />d
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, conatructlon alts, etc. (Specify)
<br />O
<br />V m
<br />m 22d. INJURY AT WORK? 22e. DESCRI9E HOW INJURY OCCURRED
<br />O
<br />F" ^ YES [~'AO
<br />22t. LOCATION OF INJURY -STREET & NUMBER, APT. NO. CITYROWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) Z ~ 24s, PATE SIGNED (Mo., Day, Yr.) 24A. TIME OF DEATH
<br />~'~ May 18, 2009 ~~z m
<br />U
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ y O 24c. PRONOUNCED DEAD (Mo., Dsy, Yc) 24d. TIME PRONOUNCED DEAD
<br />E~ i May 20 r 2009 1 1 :1 5 P. m E H a z m
<br />0
<br />u ~ To the beat of my k edge, death occurred at the tlme, data and place s w y t7 24e• On the baaia of examination and/or Invastigatlon, In my opinion death occurred
<br />o ~ an to the ca a(s) orated. (si nature and Title) $ O O at the tlme, data and place and due to the cause(s) stated. (Signature and Tide)
<br />Fa ~ f°.OV
<br />U O
<br />25. DID TOBACCO US CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? tab. WA8 CGNSENT GRANTED?
<br />^ YE8 ^ N ^ PROBABLY ~l1NkNOWN ^ YES ~tlt~ Not Applicable H 28a la Nq ^ YES ©,yo+
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Ryan Crouch, D.O. 800 Alpha 5t:, Grand Island, NE 68803
<br />28a. REGISTRAR'S S1C3NA7URE 28b. DATE FILED BY REGISTRAR (Mo., Dry, Yr.)
<br />,d , MAY 2 2 2009
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