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STATE OF NEBRASKA
<br />. WH�N THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANf�. HU4NRl�l^.SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA•DEp.�R'TMENT,bF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI�A4 R�CQRDS
<br />i
<br />DATE OF ISSUANCE i��� �. �� .
<br />STANLEY S. COOPER�
<br />Yl��► � � � ASSIS=T�INT °`�,�AI� REG7STRAR' �; ; ,' �
<br />k � DE�AR7MEIV� HEALTM�AN� °
<br />LINCOLN, NEBRASKA 2 0 1 1 O� V��J HUMLfC1h S,ERVICES
<br />� � �` rt. �1 .�
<br />,�„
<br />_ ., _
<br />STATE OF NEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES FINANCE AND SUPP T
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Ma., Day, Yr.)
<br />Robert Lee Stroud Male October 22, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE-Last Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) ,
<br />� (Yrs.) MOS. DAYS HOURS MINS.
<br />j Grand Island, Nebraska 55 November 13, 1953
<br />7. SOCIAL SECURITY NUMBER
<br />505-64-0370
<br />8h FpC;L�7V-NA�dF (It not ir.stitutinn. giva street and numb.rl
<br />St. Francis Medical Center
<br />8d. CITY OR TOWN OF DEATH (Indude Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE-STATE 9b. COUNTY
<br />Nebraska Hall
<br />��. �, � ,��, ,,;.c>.ur.;oen
<br />1612 Grand Ave.
<br />10a. MARITAL STATUS ATTIME OF DEATH y'� Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient
<br />�'i tFiGutpa[ien[
<br />❑ �Deceuent's Home
<br />❑ 004 ❑ Other(Specify)
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />9c. CIN OR TOWN
<br />Grand Island
<br />��3c.?^-7.N0 3t.Zl^CCDF
<br />� 68801
<br />NAME OF SPOUSE (Firs�, Middle, Last, Suffix) If wife, give maiden name.
<br />Melis�a Leiser
<br />11. FATHER'S-NAME (First, Middle, Last, Sulfix) 12. MOTHER'S-NAME (First,
<br />H arold Stroud Norma
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a.INFORMANT-NAME
<br />(ves,no,orunk.) NO Melissa Stroud
<br />15. METHOD OF DISPOSITION 16a. E L ER-SI AT E 16b. LICENSE N0.
<br />❑ Burial ❑ Donation �Z y�
<br />�Cremation ❑ Entombment 16d. CEMETERY, CR ATORY OR OTHER LOCATION CITY / TOWN
<br />3g. INSiDE CITY LIMITS
<br />X] vES ❑ No
<br />Middle, Maiden Surname)
<br />Carlson
<br />tdb. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr. )
<br />October 27, 2009
<br />STATE
<br />❑Removal ❑Other�Specify) Westlawn Memorial Park Crematory, Grand Island, Nebraska
<br />17a.FUNERALHOMENAMEANDMAILINGADDRESS (Street,CityorTown,State) 77b.ZipCode .
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE. 68801
<br />18. PART I. Enter the chain of evenis--diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ' APPROXIMATE INTERVAL
<br />respiratory arrest, o� ventricularfibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Atltl atltlitionai lines if necessary. �,
<br />IMMEDIATECAUSE: ' onsettodeath
<br />i
<br />i
<br />IMMEDIATECAUSE(Final (a) accidental asphyxiation �, immediate
<br />diseaseorcondiNonresulting DUETO,ORASACONSE�UENCEOF: i onsettodeath
<br />indeath) '
<br />I
<br />Sequentiallylistconditions,it �b� choking on food � immediate
<br />any,leadingtothecauselisted DUETO,ORASACONSE�UENCEOF: I onsetlodeath
<br />on line a. I
<br />Enterthe UNDERLYING CAUSE
<br />(diseaseorinjurythatinitiated (°) �
<br />theeventsresultingindeath) DUETO,ORASACONSEOUENCEOF: i onset�odeath
<br />LASf
<br />(d) i
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to ihe death but not resulling in ihe undedying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES C� NO
<br />20.IFFEMALE: 21a.MANNEROFDEATH 21b.IFTRANSPORTATIONINJURY 27c.WA5nNAUTOPSI'PE9FOAMED?
<br />❑ Not pregnant within past year ❑ Natural ❑ Homicide ❑ Driver/Operator
<br />❑ Passenger
<br />❑ YES [,� NO
<br />❑ Pregnant at time of death �Accident❑ Pending Investigation
<br />❑ Notpregnant,bulpregnantwithin42daysofdeath ❑Pedestrian p�d.WEREAUTOPSYFINDINGSAVAILABLETO
<br />❑ Suicide ❑ Could not be determined � Other (Specify)
<br />❑ Nbt pregnant, but pregnaM 43 days ro t year before death COMPLETE CAUSE OF DEATHI
<br />a�Unknown if pregnant within the past year 0 YES �l NO
<br />✓22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OP INJURY-At home, farm, street, factory, otfice building, construction site, eta (Specify)
<br />uczober� 2i 20L�S 10 :C3 P`" ;R �S ± dUrant _ Tpx T-Rone
<br />- - - --- - -- --- - _ _ -- - --
<br />22d. INJURY AT WORK? 22e. DESCFiIBE HOW INJURY OCCURRED
<br />❑YES �NO Dece��.ent. choked on a lar e iece of ineat
<br />22LLOCATIONOFINJURY-STREET&NUMBER,APT.NO. CINROWN STATE ZIPCODE
<br />�3a. DATE OF �EATH (Mo., Oay, Yr.)
<br />z
<br />a
<br />Da aUZ
<br />U __-__'-..."_ _"'"_"- y 2
<br />y� 23b. DATE SIGNED (Mo., Day, Yr.) 23aTIME OF DEATH y=�
<br />n=� ya<�
<br />amo m e��Z
<br />° c 23d. To ihe best ot my knowledge, death occurred at ihe time, date and place � w Z�
<br />� c and due to the causejs) stated. (Signature and Title )♦ g p o
<br />�Q ��
<br />24a. DATE SIGNED (Mo., Day, Yr.) i 24b.TIME OF DEATH
<br />November 19, 2009 j 12:22 am
<br />24c. PRONOUNCED DEAD (Mo., Day,Yr.) 24d. TIME PRONOUNCED DEAD
<br />October 22, 2009 12:22 am
<br />On e basis of examination and/or investigation, in my opinion deaih occurred at
<br />� the ime, date nd a e and d to the cause(s) stated. (Signature and Title )♦
<br />��� ��,�� p�� Deputy Hal l
<br />25.DIDTOBACCOUSECONTRIBUTETOTHEDEATH? 26a.HASORGANOFTISSUE�9WAHdI�BEENCONSIDER�D? 26b.WASCONSENTGRANTED? - -
<br />❑ YES ❑ NO U PROBABLY � UNKNOWN ❑ YES q(NO Not Applicable if 26a is NO ❑ YES � NO
<br />27.NAME,TITLEANDADDRESSOFCERTIFIER (PHYSICIAN,CORONER'SPHYSICIANORCOUNTYATTORNEY) (TypeorPrint)
<br />Sarah L. Carstensen De ut Hall Count Attorne 231 S. Locust St. Grand Island NE 6880]
<br />28a. REGISTRAR'S SIGNATURE � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />' ,((. NOV 2 5 2009
<br />OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility
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