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STATE OF NEBRASKA
<br />. . ' r -�'. � .
<br />� WHEN THIS COPY CARRIES THE RAISEU SEAL OF THE NEBRASKA DEPARTMENT OF HEALTff �,1fQ AlV ,�RV{G'ES, IT CERTIfI�S
<br />THE BELOW TO BE A TRUE COP1` OF THE ORIGiNAL RECORD ON FTLE WI7'H THE NEBRAS1t�D �T �JYT� DF„WPAL7N AND .
<br />tfUMAIV SERVICES, 1/ITAL RECORDS OFFICE, WHICH IS THf LEGAt DEPOSITORY FOFF;.tl�T,4�,������°r'",.1 �.. ,.
<br />ti .
<br />DATE �F ISSUANCE . �
<br />,
<br />, r��M!'Lf��� � ' � +� 4 ":`� � l
<br />02/02/2011 r' ; :
<br />2 0 i 1017 5 � ,��, .n ., � �� ,; �
<br />LINCOLN, NEBRASKA , H�A�` . � • ,,r
<br />K d 9 A � � �'� � � ,� � .
<br />STATE � NEBRA3 �ERT FICATE O R�ATHHUnaAN ��3�c"�'✓� �� �''. �'�� � 0. 00225
<br />1.DECEDENTS•NAME (Firsk Middle� LasR Sufflx) 2.SEX ;•',Jt�i ,5.�lAT , Ok'J�►M1�,D�Y�Yr.)
<br />Benjamin Martin Somer AAa4e �... :t�nu# ' 19, 20"t0
<br />. CITY ANO STATE OR TBRRITORY, OR ROREIf3N COUNTRY OF 8U2TF1 5a. ARB • Lut BIrUWay . UNpER 1 YEAR Sc. U11�R 1 OAY ' C TG OF 111R1'H �Mo„ �y, Y�.)
<br />(Yrs.) MOS. �YS HOURS rrIM1S.
<br />Walnut, Nebraska 8T February 11,1922
<br />7. SOCIAL 3ECURffY NUMBBR Yi. PLACE OF DEATH
<br />506-14-4608 �PtIB{. ($1 �^vaue� Qj�B ❑ Nunfnp Honre1LTC [] Hospice FacNlty
<br />Bb. FACiI.ITY-NAb1E (M not IMtitutbn, @Ne streat and r►umber) � ER/p�tpa�eM � Deced�M's Home
<br />g Saint Francis Medical Center ❑� �°tl'•r �
<br />� .
<br />. cm oR Tqwn� oF �►rH pnduaa z� coa.� sa. couFrrt oF o��tt
<br />Grand Island 88803 ��
<br />� 8a. RESIDENCE•STATE 8b. GOUNTY 9C. CI OR TOWN
<br />Nebraska Hall Grand Island �
<br />� ed. STREET ANP NUMBER . APT. NO. 9E. ZIP CODE tlp, INS10E CIiY tqYHTB
<br />�' 2222 W Oklahoma �� �'� ❑ �
<br />� t0a. AAARI7AL STATU8 AT TIME OF QEATH � lAaRkd ❑ Nava MasrlW 10b. NA1Y1� � SPOUa6 �Rkst, MMdI�, Last, Suffix) if wfFa, Wv� malden nsrta
<br />❑ MarHad, but wparated (] Widow�d ❑ DNOrced ❑ Unknown phy�hS ,J Bf8dN�911
<br />11. FATHER'$-NAM6 (FIrs4 AAiddle, I.as; S�flx) 1Z. MOTH6R'8�NAME (Rirst, Middle, MaicNn Sumame)
<br />Joe J Somer Auguata H Blodc
<br />� 13. EVER !N U.S. ARMED FORCES? GWe dates ot �eMca H Yes. 14a. INFORMANT•NAME 14b. REI.AYION9FIIP TO OECEDENT
<br />$ (res, No, or unk.> Yes 07/01/1942-02/26/1946 Ph lis J Somer Wife
<br />�' 15. METHOD OR DISPOSITION 7 W. EkiBA1.MER-816MATURE 18b. LICENSE NO. 18c. ORTE (Mo., ORy, Yr.�
<br />r � sw�ai ❑ Do�tlon y ��� a R C � y � 1092 Janua 23, 2010
<br />❑ Cromation ❑ EMoombmerk �8d. CEMETlRY, CREMATORYDR OTFIER LOCATION CITY � TOWN STATE
<br />� R ��� ��� Westlawn Memorfal Park Gemetery Grand Island NebraSka
<br />17a. FUNERAL HOME NAM@ AND MAIUN6 ADDRE9S iStre�t Ctty w Towrr�, Sptel 17b. �p CodO
<br />Curran Funeral Chapel, 3005 5. Locust St., Grand Islantl, Nebraska ��� .
<br />so ruc n$ an �xam es
<br />� 16. PART 1. EMer tM chaM of rwm�.�0inaias. Mlude�. w coroplkatlonrdAM directlyr osuwd t6a dsNh. DO NOT sr� tartMnal owM� ruch n wdbc arroN. i APPROX�AAATE INTERS/AL
<br />rospiratory amst, or venGiculu IIbAilpGon wlthout thawMp ths aNOlopy. 00 �WT AOBRFWATE.S.� only au cpua on l tine. Add adEtGOnW Nnss tt+»aaary•
<br />IMMEDIATE CAUSE: ; o�uust to de�q�
<br />IMMEDMTB CAUSE� (FMaI a) Complete Heart Block - � ; MiflUtC8
<br />aNaaa or condNion nwklnY . � . . _ . � . .
<br />M aaaq DUE TO� OR AS A CONSEQUENCB OF: � aaN Es Ma&�
<br />S�pwaWlly tl�t WndftiOnt, I� b)Anemia � . � . � � � � � . � e Days � � � � " -
<br />� anY. ��np to th� auss tisNd � .. . ; . .
<br />on firn a. DUE T0� OR A CONSE UEN O: 0 OM1t to iath
<br />EMer the UNDERLYING CAUSE �) Gastric Cancer � : Months .
<br />(msea.a or u�Jury mat �mNa.a . �
<br />ehe ev��ta nsuleMq in uwthl p�yE SO, Oit AS A CONSEQUENCE OF: : onset t0 dWth
<br />u�sT d �
<br />18. PART il. OTHER 91GNIFICANT CONDITIQNS�Co�IGora corNAbutiny W tta dwth but not rosultl� in ttro undsryl�{{ cause 8ive� in PART L 18. WAS MEDICAL BXAAIANER
<br />Chronic Obstructive Pulmonary Disease OR CORONER CONTnCTED�
<br />� [] YES � NO
<br />� 0. tF FEMALE: 21a. MANNER OF OEATH 21b. iF TRANSPORTATION INJUR Ytc. WAS AN AUTOPBY PERFORMBD?
<br />� � Not Prop�M wlMin WM YN� � Nafwal � Homidd� [a orNsrropaator �� YES � � NO � .
<br />� PropnaM at time oi deatli ����d�� � Pe�dry� �� [� Passenper �
<br />V Not prspnant but propnant wltnM az dqs W dam � � �� a asdaatdan . 21d. M�RE AIlTOPSY FMrWNN68 AYAIL.NBL
<br />� � NM Pro��4 but Pn9naM 4D days to 1 yar bNon dNth � � SukMe � co�w �a w a.a�.e � anN ($v. ro coa►w.Ere cnusE �of oEAtH� �
<br />� [] unw�wm n a�anam wnron me ws� rar � YE1 Q NA
<br />y 2Za. DATE OF INJURY (Mo, �ay, Yr.) 22b. T1htE OF INJURY 22c. PLP��CE Of INJtlRY-At home, farm, strost, iactory, oMles buNd��� aantructWn sNa� a1e• t��Yl
<br />�
<br />� 22d. INJURY AT WORK? 22e. DEECRIBE HOW INJURY OCCURRED
<br />1�-
<br />� YES �} NO
<br />22(. LOCATtON OF INJURY • S7REET 6 NUMB@R, APT.NO. CITY/fOVYN STATE ZIP CODE
<br />2St. DATE OF DEATH (Mo., Qay, Yr.) __ 24s. DAtE SK3NED (Mo., Day, Y►.) 24b. TI E QF DFr4Tft __
<br />_ _ _ --
<br />� January 19, 2010 3� �
<br />23b. DATE s10NBD (Mo., Day, Y�.) 28c. TIME O� DEATH � 24C. PRONOUNCBD DEAD (Mo., Day, Yr. 24d. TIMB PRONOUNClD DFAD
<br />� Janua 26 2010 08:67 PM <'
<br />� o w. To Hw Mot ot my knowqepe, dwtl� occuma ae tne txn, dab an9 paa �� s�a, Oa aw baNs ot sxarMnsqon and/or inwNqallon, in � opMlon dealh occump �t
<br />� t E �3 tRe qme, dxe and pMa mA due to Me awNs► aaf�. IBynMOn �d T1HW
<br />8 en9 Aw�to dr esusslsl staNd. (SlynNtm a� THM) � o Li -
<br />~ Travis S. Hageman, MD '' a
<br />2'3. DI TOB O USE CONTRI UT O T EA H? 26a. HIl.9 OROAN OR 38t1L° A710N BE�N 09 26b. W f �
<br />� YES ❑ NQ PR09ABLY UNKNOWN YES NO Not Applicabb H 46a p NO YES ❑ NO
<br />YP� c►
<br />Travis S. Hageman, MD, 729 North Custer Averwe, Grand Island, Nebraska, 68803
<br />2ia. RE6ISTRARB SIQNATURH 28b. DATE FILED BY REGIS7RNt (Mo„ DaY, Yr.�
<br />� February 1 � 2010
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