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<br /> STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT,HAWD'14t*YAIV SERVICES, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ~~1L~A~ Tdt1E 1 t E rEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR-VLTt4~L. R RDS...
<br /> DATE OF ISSUANCE
<br /> $'TANL•EY OpPfR--
<br /> AUG 3 1 2010 201007054 ~Ss~IST~nrTG~
<br /> PEPARTMENT OF HEALTH ,9N4~
<br /> LINCOLLY,4(E88dSK.9_-- _ MyMs4(0.S'FRVIOES• c:
<br /> STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVWES ` a t
<br /> F a O'
<br /> 1. DECEDENT'S-NAME (First, Middle, Last Suffix) 2. SEX
<br /> Robert L Driml Male August 11, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE-Last Birthday 6b. UNDER 1 YEAR 8c, UNDER I DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Mullen, Nebraska 81 July 4, 1929
<br /> 7. SOCIAL SECURITY NUMBER 6a. PLACE OF DEATH
<br /> 508-28-1538 HO§rjM: ❑ Inpatient QTg51{;'[] Nursing Home/LTC © Hospice Facility
<br /> 8b. FACILITY-NAME (t not institution. give street and number) ® EIUOutpationt ❑ Decedent's MGM
<br /> Saint Francis Medical Center ❑ DOA []Other(Specify)
<br /> 8c. CITY OR TOWN OF DEATH (include Zip Code) Rd. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> so. RESIDENCE-STATE Sb. COUNTY Sc. CITY OR TOWN
<br /> Nebraska Hall Aida
<br /> Sd, STREET AND NUMBER Se. APT. NO. SL ZIP CODE Sg• INSIDE CITY LIMITS
<br /> 52 Venus Street 68810 Yes No
<br /> tot. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Naver Married tgb. NAME OF SPOUSE (First Middle, Last Suffix) K wits, give maldsn name.
<br /> ❑ Married, but separated ❑ Widowed W Divorced ❑ Unknown
<br /> It. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First Middle, Malden Surname)
<br /> Uqf Louis Driml Beulah Sims
<br /> Rl 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yee. 14t. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> t°- (Yea, No,aru"k.) Yes tl3/21/t951-12/2tl/195-2 re gory Driml Son
<br /> 16. METHOD OF DISPOSITION lea. L R-SIGN 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.) -
<br /> ®aa"al []Oonat- ~ August 14, 2010
<br /> ❑cnm.uon ElEMOmbreanl
<br /> []RMnoval ©Onherlapecify) 16d. CE ETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> Kearney Cemetery Kearney Nebraska
<br /> 17s, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, natal 17b' Zip Code
<br /> O'Brien-Stmatmann Funeral Home, 4116 Avenue N, PO Box 2344, Kearney, Nebraska 68847
<br /> CAUSE OF DEATH See instructions and examples)
<br /> Ia. PA T n. enter nhe Myla of - ap - diseases. Injud". or campllcaadns. that rectiy min" the deakh. DO T saner tanisnal events such as eardlec amst APPROXIMATE INTERVAL
<br /> resphatary *met. or veamcular fibricollon whheut showing the edclosy. DO NOT ASMUMTE. Eller only sae cause aft a Iles. Add additional lines It n cmue y.
<br /> IMMED E AUSEI t onset to death
<br /> IMMEDIATE CAUSE (Final
<br /> disease or condition resulting a)
<br /> In death)
<br /> DUE TO, OR AS A CONSEOl1ENCE OF: ; onset to death
<br /> Sequentially list condition, If ~(/"p'
<br /> any, leading to the cause listed b) J[.~ 1 ('b V64 al& / V
<br /> on line a. DUE TO, OR AS A CONSEQUENCE OF: on" death
<br /> Enter the UNDERLYING CAUSE c)
<br /> (disease or Injury that initiated
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br /> LAST
<br /> d)
<br /> 16. P IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the Bath but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br /> TED?
<br /> r ^ OR CORONE;7,
<br /> 1 ©YES
<br /> tU 20. IF FEMALE: 21s. ANNER OF DEATH 21b, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY P)fRFORMED?
<br /> W
<br /> ]r [I Not pregnant within pest year Natural El Harrhicide © DrIveNOperaWr © YES ,L.ll O
<br /> W ❑ Pregnant ■t time of death Accident ❑ Pending Investigation Passenger 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> L) ❑ Not pregnant but pregnant within 42 days of death ❑ Suicide Could not be deterrolned ❑ Pedestrian TO COMPLETE CAUSE OF DEATH?
<br /> ❑ Not pregnant, but pregnant 43 days to 1 year before death Other (specity) YES QXO
<br /> []Unknown. if pregnant within the past year
<br /> 7241. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street factory, office building, construction site, Ste. (Specify)
<br /> V m
<br /> 224. INJURY AT W RK7 22e. DESCRIBE HOW INJURY OCCURRED
<br /> F
<br /> 'Q YES O
<br /> 22f. LOCATION OF INJURY - STREET 6 NUMSER, APT. NO. CITYITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Ma., Day. Yr.) 240. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> Ly August 11, 2010 1, L) m
<br /> 236. DATE SIGNED (Mo., Oty, Yr.) 290. TIME OF DEATH 240. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> gg Au t 16r 2010 9:56 am °i` m
<br /> rrryyyyr~~~~1111 0
<br /> 2 . To the 41st of my knowledge, death occurred at the ame, date and place 24a. On the basis of examination and/or Investigation, in my opinion death occurred
<br /> and du o th cause(s) *tat d . 02 O at the tms, date and place and due to the cause(s) stated. (Signature and TIUa)
<br /> O O
<br /> to o
<br /> 25.0113 BAC USE CONTRIBUTE TO TH O TH? 28s. HAS ORGAN OR TISSUH ATION SEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> [J Y a NO E] PROBABLY NKNOWN ❑ YES NO Not Applicable If 26a is NO ❑ YES NO
<br /> k127. NA TLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br /> Jahn A. Wa dner M.D.. 800 Al ha Street: Grant? Island NF 68803
<br /> 28a. REGISTRAR'S SIGNATURE11 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> P ,(1 • AUG 2 7-2010
<br />
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