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STATE OF NEBRASKA � 0 �' �" Q 3 61 �'
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIF/ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORO (yN FILE; WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEM, VITAL STATrST/C5 �E�f7CIN�r l�
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. '
<br />� � k
<br />DATE OF ISSUANCE '
<br />� �r��, �,
<br />U�l�� � � ��� � 7AN��Y,{S: �(��Q�,�t s , , ,� '
<br />asst�'�.��v�:s�ar� �t�a�.'�� � � � �
<br />LINC96A1, NEBRA�KA-- - - - - - _ HEALTM,�Mi� HUIVI�IIU �1'�V/C�� . r'
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMARP'S R �`E9' ' l '� '° '
<br />0
<br />22L LOCATION OF INJURY - STREET 8 NUmBER, APT. N0. CITYITOWN STATE ZIP CODE
<br />23a DATE OF DEATH (dso, Day, Yr.J �� 24a. DATE SI6NED (470„ Day, Yr.) 7Ab. TId1E OF DEATH
<br />a� March 21 , 2008 �.� m
<br />. �� 23b. DATE SIONED (dlo., Day, Yr.) ,23c. TIME OF DEATH g� O 24c, pRONOUNCED DEAD (BAo., Day, Yr.) 24d. TIME PRONOUNCEO OFAD
<br />' E�Z � dtPc,� ��', 'Z� � 8: 42 P, m a�a �
<br />3s� E� o "'
<br />.a e �d. �o tlre �my owled8a. death axurted at the tMre, dete emi plaee ��� 24e. On the b�is M e:amineUon ertd/or Irneatlgatlon, in my oplNon deafU aeciured
<br />o � .�si¢n�cure end nual $ o o et the tlme, date arM ptaee arM due to the cause(s) stated. (Signadue aml TIUe)
<br />F o � .
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<br />28 DI� TOBACCO USE COMRIBUTE TO THE OEATH9 ZBa. HAS OROAN OR TISSUE NATION BEEN CONSIOERED7 266. WAS CONSENT ORANTED?
<br />YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO . Not Applicable U 28e Is NO ❑ YE9 � NO
<br />27. NAME, TITLE AND ADDRESS OF CERTiF1ER (PHYSICUW, CORONER 8 PHYSICIAN OR COUI�TY ATTORNE1n (Type or PrIM)
<br />Travis Hageman, M.D., 729 N. Custer Ave., Grand Island, Nebraska 68803
<br />ZBa. RE(itBTRAR S SIGNATURE 266. DATE FlLEO BY RE(iiSTRAR (AAa� DaY. Y� 1
<br />P ��l�►/>� 1� ��i► , MAR 3 1 2008
<br />CE TI CATE OF D H "'��a �.
<br />1.DECEDENT&NAME (F7rst, d1lddle� Lest, Su1H�c) Zgp� ,�,.,�,
<br />M31 E� ., :,���
<br />Robert Henry Zersen � ' -
<br />4. CITY AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH Ba AOE-I,ast Blrthdey 86. UNDER 1 YEAR 8c. UNDER 1 DAY
<br />(Yre.) 6705. DAY9 HOURS dUN9.
<br />Omaha, Nebraska 77
<br />7. SOCULL &ECURITY NUAABER � Ba. PLACE OF DEATH �
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<br />Bb. FACIUTY•NAd1E pf rrot InatldMon, ghe atreet a�M number)
<br />Saint Francis Medical Center
<br />e�. cmr ore rown oF oenrrr �m�uae ap c��
<br />Grend Island 68803
<br />9a. RESIDENCE-STATE Bb. COUNTY
<br />Nebraska Hall
<br />Bd. STREET AND NUOABER
<br />2740 Binfield Rd.
<br />10a MARITAL 8TATU8 AT 17ME OF DEATH � Mertled � Never Mat
<br />p m��a, �„e � O wna�a p m„o�ea Q u�a�a�
<br />17. FATHER'S-NA40E (Ftrst, Middle, Last, SuRix)
<br />13. EVER IN U.S. ARMED FORCESI G(ve detea of aerWce
<br />1Yes, no, or unk.) Yes 09/18/1952 Z/19
<br />18. PQETHOD OF DISPOSITION 16a. EM
<br />�B�ulal OOonatlon �
<br />❑cre�n� p�mw,�M
<br />QRmnwal QOtfier(BPetifl) C '� '
<br />cF� �1, 2D08
<br />TE OF �BIRTH (blo., Dag Yr.)
<br />November 28, 1930
<br />HOSPITAL: Q InpaBetR oTM�: 0 Nwaing Homeil.TC � Hoapice Fac0lty
<br />❑ ER/�utReNettt � �cedeM's Home
<br />❑ �A ❑ �rt$a�rl
<br />ad. couKrr oF n�rH
<br />Hall
<br />Bc. CITY OR TOWN
<br />9a. APT. NO. 8f. LP CODE 9g. WSIDE CIM LIAAITS
<br />68832 Q res � No
<br />10b. NAAAE OF SPOUSE (Flist, Mlddle, t.eat, Suftix) U wifa, glve msiden nama
<br />Marlene Lehmkuhler
<br />1Z ApOTHER'SNAd1E (Flraf, Nliddle, AAatden Siuneme)
<br />14a MFORMANT-NAME
<br />Marlene Zersen
<br />-���wq�� • 18b. LICEN9E NO.
<br />u,2 � af �� q'
<br />crs�eeaTO�r oR orHea � noN cmrrrowN
<br />� Cedarview Cemetery
<br />17a FUNERAL HOOAE NAME ANO MNLINO ADDRESS (Streey City or Tmrm, State)
<br />All Faiths Funeral Home, 2929 S. Lacust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and
<br />78. PART L Entetiho s6aln aleverea' dls�aea, inpui�� m eomp�ICetlp�m.gret ai�eWY ea�eed We Eeath• DC NOT ertBftBlmUm1 epeMg euth 99..
<br />�P��rY �. m'veM�iaularllhrlltatlon wiNwt ahoainp tde etlology. DO NOT ABBIiEVIATE BMe� only am cavee ml a M4 Add adtliHo�l
<br />IMdAEDIATE CAUSE:
<br />IdIA7EDtATE CAUSE (Flnal //�
<br />dtaeese or eonditlon reeWtl� a) � 1�, � t /: y� � A, �,
<br />In deeth) - - d IAl � � �i �
<br />DUETO,ORASACO CEOF:
<br />aequanna�ry uat oond�nons, �r
<br />enY. leading to fhe cause Ilated b)
<br />on Urre a DUE TO, OR AS A CONSEQUENCE OF:
<br />F.Mer the UNDERLYINO CAUSE c)
<br />(disease or injmy tl�at initleted
<br />tlre evenfa resWy� In death) DUE TO, OR A8 A CONSEQUENCE OF:
<br />LAST ;
<br />' o�reet to death
<br />I
<br />I
<br />; an86t to death
<br />�
<br />19. WAS O�EDICAL E%AMINER
<br />OR CORONER CONTACTED?
<br />� � NO
<br />Z1a WAS AN AUTO�PSY PERFORMm?
<br />❑YES 17GN0
<br />/�
<br />21d WERE AUTOPSY FW DIN(i3 A4pILA8LE
<br />TO COMPLEfE CAUSE OF DEATHZ
<br />❑ YES �NO
<br />a
<br />O ZYa. DATE OF WJURY (AAo., Day, Yr.) .22b. T167E OF INJURY 2Yc, pLpCB OF INJURY-At home, tanr�, atraet, tactory, oHice bWlding, constructlon slte, etc. (SpecHy)
<br />V
<br />� Z2d. INJURY AT WORK? 22e. CESCRIBE HOW WJURY OCCUt3RED �
<br />~ ❑ YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wlfe
<br />18c. DATE (mo, Day, Yr.)
<br />March 29, 2008
<br />STATE .
<br />Nebraska
<br />176. Zip Code '
<br />68801
<br />�•
<br />i o�reet to death
<br />� � �����
<br />onaet to death
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<br />18. PART tl. OTHER SIGNIFlCANT CONDITIONSConditlo�m coM�ibutlng to the death but nM reaulting In the undeAyinB Qease B�van in PART L
<br />Cv`��.
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<br />�• � F�� � 21a dWNNER OF DEATH 27b. ff TRANSPORTATION INJUF
<br />F ❑ Not prepnaM wtthin past year �atma� ❑ Homlcida ❑ DrivadOperator
<br />� ❑ Pregnant at tlme of death �--� .
<br />❑ Acc[deM � PeMn� Inreauaat�on ❑ Pasaenger
<br />❑ Not P+88�attf. but Pre9nant wifhln 42 daya of death p s�t�iao p cowa �oc ae a���ea p Pea.ewen
<br />� ❑ Nct Pregnanf, But P+'�9��� 43 daya to 1 year be(ora death �❑ Othar (SPec(fp)
<br />� ❑Unlmown H
<br />Pregnant wifhin the p�t year
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