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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL37'f'AND l-lUh~A~1f:SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE~RA~K~q yl7fPgh1-MENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F06t' VLTgL;~E~S.-
<br />DATE QF ISSUANCE ~• ~~
<br />05/26/2010 2 o i o 0 3 s o s ~~ s~A;~ ~ISTRAR
<br />DEA!]I~TMENT OF 1-1EALTH:gND
<br />LINCOLN, NEBRASKA HUI~jgN.S,~~,VICES • , ': •'
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SER1dtCE~~ ~• • .. , , _ • .. 10 01429
<br />CERTIFICATE OF DEATH ~ ~ ~ ~ - -
<br /> 1. DECEDENT'S-NAME (Flrat, Middle, Last, Suffix) 2. SEX 3: DATE OF DEATH (MO., Day, Yr.)
<br /> Glenn Eugene Robets Male May 20, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Boelus, Nebraska 73 December 17, 1936
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 506-50-1194 P T ^ Inpatient OTHER ^ Nursing Home/LTC ^ Hospice Facility
<br /> 8b. FACILITY-NAME (H not Institution, give arrest and number) ®ERlOutpatient ©Decedent's Home
<br />lY
<br />O
<br />U Saint Francis Medical Center ^ DOA ^ other (specify)
<br />~ 8c. CITY OR TOWN OF pEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br /> 8a. RESIDENCESTATE 8b. COUNTY ec. CITY OR TOWN
<br />w
<br />z Nebraska Hall Wood River
<br />~ 9d. STREET AND NUMBER e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />~, 207 W. 11th St. 68883 ®YES ^ No
<br />
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 10h. NAME OF SPOUSE (First, Middle, Last, Suffix) H wHe, glue maiden name
<br />!E
<br />d ^ Married, but separated ^ Wldowad ^ Divorced ^ Unknown Shirley Joan Schroeder
<br />
<br /> 11. FATHER'S-NAME (First, Middle, Last, suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />~ Earl Roberts Amelia Larsen
<br />q'
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates of service H Yas. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yes, No, or unk.) Yes 02/27/1957-05/26/1961 Shirley Joan Roberts Wife
<br /> 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />~
<br />~ ®8urlal ^ Donation Laurie D. Sheffield 1397 May 26, 2010
<br /> ^ Cretnatlon ^ Entombment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (SpecHy)
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> RUSE F D A H ee ns ruct ores an exam es
<br /> 1a. PART I. Enter the chain of events--dlwawa, Injuries, or compllptlonadhat dlroctty posed the death, p0 NOT enter terminal events ouch as cardiAC arcast, ;APPROXIMATE INTERVAL
<br /> reaplratory arrest, pr ventricular abrlllatipn wlthput shgwing the atlplogY• 00 NOT AB6REVIATE. Eller only one cauw on a line. Add adtliticnal Ilnea If naCaswry.
<br /> IMMEDIATE CAUSE: ; Onset t0 death
<br /> IMMEDIATE CAUSE (Pagel a) Renal Failure 3 Months
<br /> dlaeaw or condition resulting
<br /> In death) DUE TO, OR As A CONSEQUENCE pF: ; Onset t0 death
<br /> saquan[lally Ilat condlllona, Ir b) Diabetes Mellitus 50 Years
<br /> any, Iwding [q the puns Ilated
<br /> on Iina a. pUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (diaww or Injury that Initiated
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> LAST d)
<br /> 18. PART II. pTHER SIGNIFICANT CONDITIONS-Conditions contrlbutlna to the death but not rasuHing in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER
<br /> Respiratory Failure, Congestive Heart Failure,Dementia OR CORONER CONTACTED?
<br /> ^YES ®NO
<br />~,
<br />W
<br />LL 20. IF FEMALE: 21 a. MANNER OF DEATH 27b. IF TRANSPORTATION INJURY 21 C. WAS AN AUTOPSY PERFORMED9
<br /> ^ Not prepnarn within past year ®NAturdl ^ Homicide ©DrlwdOperetor
<br /> ^ YES ® NO
<br /> ^ Prognant at time of death ^ Accident ^ Panding Invas[Igatlon ^ Paawnger
<br /> ^ Not pregnant, but pregnant within 42 days of death
<br />^ Suicide ^ Could not ha determined ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />©Nqe pregnant, hW prognaM 49 days to 1 year befpro death
<br />©Other (Specify) TO COMPL@TE CAUSE OF DEATH?
<br /> ^ Unknown If pregnam wthin the past year ^YES ^ NO
<br />a 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, Tactory, office building, construction site, etc. (SpecHy)
<br />
<br />.~ 22d. INJURY AT WORKT 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />~
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. Cn'YITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />a ~ May 20, 2010
<br />~ 24a. DATE SIGNEO (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> ~ ~ r 234. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ ~ ~ r Z4c. PRONOUNCED DEAD (Mo., Day, Yr.- 24d. TIME PRONOUNCED DEAD
<br /> ~ z Ma 25, 2010 04:25 AM ~ d ~ Z
<br /> O 3d. To the twat of my knowledge
<br />death occurre0 at the lima
<br />daW and place ~ ~ O
<br /> ,
<br />,
<br />d
<br />S w
<br />~ 24s. On ell baste pf examinatlgn and/or Investlgatlon, In my opinion death occurred at
<br /> due to taw Cduw(t) amrod. (
<br />ignature antl TRle)
<br />H an ~ p the time, tlaW antl place antl due to the Cauw(a) elated. (Signature and Title)
<br /> ~ David R. Colan, MD ~ 8 `
<br />0
<br /> 25. DID TOBACCO USE CONTRIBUTE TD THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PR08ABLY ^ UNKNOWN ©YES ®NO Not Applicable If 28a Is Np ^YES ^ NO
<br /> AN , N pe or r n
<br /> David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE ~ 28b. DATE FILED BY REGISTRAR (MO•, Day, Yr.)
<br /> _ May 25, 2010
<br />
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