|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAl. OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN'SE'RVIGES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE W1TH THE NEBRASKA DEPARTMEAF'f:,Of ff�A1;�H AND
<br />HUMAN SERVICES, V1TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RE�QitO���y�, �
<br />--� � :�� r ;
<br />DATE OF ISSUANCE ��/��������`����
<br />�EC .15 200� $T1�����. ������ � ,� 4 ��� �°�,�
<br />assr�r�vr'sr,�rE �r�rs5�t� ���
<br />��1 � 1� 7 2 0� D�����r a� � i�a�rri ��; s: q� _
<br />LINCOLN, NEBRASKA HCll�f"�I t��£'R E "° � � : � � �;� �� _
<br />- - -- -- -- � . � a�-��� �
<br />� ... , �. - �- : ' :� �
<br />� �, . . � ,� � �
<br />_ _ , c� ',..+� � � ' n, a�
<br />��
<br />�. -
<br />. . 9 �� � � � S � T. � �s
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN 3ERVICES FINANCE AND SUWP� '••.�� �S;°� � -°
<br />CERTIFICdTE OF DEATH �.. �11. . til'���
<br />1. DECEDENTS-NAME (Firat, Middle,
<br />Robert Francis
<br />4. CITY AND 9TATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH
<br />ockville, Nebraska
<br />7.60CIAL SECURITY NUMBER
<br />508-12-0345
<br />Bb. FACILITY-NAAOE (If not inatltution, pive atreet and number)
<br />St. Francfs Medical Center
<br />8a CITY 0R TOWN OF DEATH (Uiclude ZIp Caie�
<br />Grand Island 68801
<br />9a RESIDENCE-3TATE @6. COUNT/
<br />Nebraska Hall
<br />BdSTAEETANONUMBER
<br />8c. CITY OHTOWN
<br />Grand Island
<br />Be.RPT.NO Bf.ZIPCODE Bg.IN810ECITYLIMRB
<br />6.RAf1� � YE8 ' ❑ NO
<br />10a. MARITAL 3TATUS ATTIME OF DEATH �,1 Mgrrted 0 Never MaMed tOb. NAME OF SPOUSE (Fhst, tdtddle, Lest, Sun4c) It wite, give meiden name.
<br />❑Merr(ed,butaeperated OVPiddwed ❑Divorced ❑Unknown pirginia Cronin
<br />11. FATHER'S•NAME (Flret, Mlddle, Last, SuHix) 12. MOTHER'S-NAIdE (pirat, Middle, Maiden Surname)
<br />Fred Moome So hie Ni ls n
<br />13. EVER IN U.B. ARMED FORCES7 Qive dates af aerv�Ce if yea. 14a INFORMANT NACAE 14b. RELATION9HIP TO DECEDENT
<br />(Yea,no,orunk) yeg 8-1 2 1-1 45 V inia Moome ife
<br />18. METHOD OF DISPOSRION 18a_ BALMER-SIONATUHE 16b. iICENSE Np. 1 Bc. OATE (Mo., Dey, Yr. )
<br />�ei� ❑Doneff'°" �-'�' � 1 Dece ber 10 0
<br />❑CremeHcn DEntombment 18d•CEMETEHY,CREMATOHYOROTHERIOCATION CITY/TOWN STATE
<br />❑ Remwai 0 Other (6pecNy)
<br />� Grand Island City
<br />17a FUNERAL HOME NAME AND IdAILIN� ADDRE9S (3treet, City orTown, State)
<br />CITYIfOWN
<br />1& PART I. EMei ihe chain of events--diseeses, inJuttes, or complicatlnne-that direc0y caused Ne death. DO NOT emerterminal evenfs such as cardiac etteat, � APPROJpMATE INTERVAL
<br />�
<br />reaplratory arreaG or vemr�uler fibripatlon wMhout shcwing tha etlology. DO NQT ABBREVIATE. Enter only one aauae on e 1hre. Add admUo�ml Mea U necessary. �
<br />IMMEDIATECAUSE: • � prreettodeath
<br />X
<br />��.��� �� Acute cardiopulmonary arrest ! � c�g �
<br />����� DUETO,ORASACONSFAUENCEOF:. i onsettodeath
<br />.Ndeffih) � � � �
<br />s�n��pr���� �°> Acute myocardial in£arction ;
<br />�'� DUETO,ORABACONSEDUENCEOF: ' i onsetudeath �
<br />onp�ree.
<br />EM�9reUNDEFRYUitiChU9E �
<br />�m�eorm�uymaz�a c�l Ghronic obstructive pulmonarq diaease '
<br />������� OUETO.ORASACONSE�UENCEOF: i onsetrodeath
<br />tA4�
<br />1
<br />�� �
<br />18. PART II.OTHER SItiNIFICANT CONDRIONS-CandlUona conWbudng to ffie death but rrot resuitfng in llre wMedying ceuse given in PART I. 19. WA3 MEDICAL E)(A641NEFl
<br />1� ORCORONER
<br />❑ YE8 L�J NO
<br />20.IFFFIWAI.E: 21aMANNEROFDEATH 216.IFTRAN3PORTATIONINJURY f ?1c:WA3APIAUTOP3YPERFORME01
<br />O Not pregnant wilhin past year x �a�� ❑ Homidde ��roPe�r
<br />❑ Prepnant at Ume of death ❑ Accltlent0 Pemltng Imestlgadon � P��"ge� ❑ YE9 �0
<br />❑ Not pregnant, but pregnaM wMhin 42 days ot deeth � P ���� 21d WERE AUTQPSY FlNDIN(9S AVAII.ABLETO
<br />❑ Suicide ❑ Could irot be determined ��� (s ��
<br />❑ Nalprepnenl,hulprepnent43deyeMlyearbeMredeath , r COMPLETECAUSEOFDEATHT
<br />❑ Unknmm It pregnant witMn Ure pasi year ❑ YE8 ❑ NO
<br />22e. DATE OF INJURY (Mo., Day, Yr.) -22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street,lactory, oHice building, consWClion sile, ero. (9peci�r) �
<br />_tm - - __ - - ---- -- --- --- -_
<br />22d.INJURYATWORK? 22e.DE3CRIBEHOWINJURYOCCURRED � � � �
<br />❑ YE9 0 NO
<br />Y1J. LOCATION OF INJURY - STREEI' & NUMBER, APT. N0.
<br />23a. DATE OF DEATH (Mo., Day, Yc)
<br />�� ' December 6, 200$
<br />� � �.DATESIONED(Mo.,Day,Yc) . X
<br />6' Decem er- 008
<br />8 . � 23d.To the b. kn g dea ned f
<br />o � � ertd du } ted.
<br />t� �
<br />❑ YES
<br />17b. Zip Code
<br />944E ZlPCODE
<br />� �� 24a DATE SIt3NE0 (Ida, Dey, YrJ 24b.17ME OF DEpTH �
<br />$ m
<br />TIPAE OF DEATH ��� 24c. PRONOUNCED DEAD (Ma, Day, Yr.) , 24dTIME PRONOUNCED DEAD
<br />DEATH?
<br />❑ UNKNOWN
<br />28a. NE�ISTRAR'8 SIONATUHE
<br />�00 m m a'¢ m
<br />date and place ���� 24e. On the basis of exeminaUon andlor Investlgatlon, in my opinlon death acurred at
<br />! �.� �$ the tlme, date end place and due to Ne ceuse(aJ ateted. (Signelure end Tttle )♦
<br />��i% ~
<br />8
<br />286. HAS OR�AN OR TI33UE DON OPl BEEN CONSIDERED?' �Bb. WAS CONSENT �RANiED7
<br />Y
<br />0 YES NO ��� Noi AoolicablB It 26a le NO ❑ YES ❑ NO
<br />Laet, SuHix) 2.SEX 3:DAT€OFDFI�TH(Ma
<br />Moomep Male December�6,2008
<br />6a. A�E•Last Birthdey fib. UNDER 1 YEAR Bc. UNDEN t DAY 8. DATE OF BIRTN (Ma, Dey,Yr.J
<br />(Yre.) MOS. DAYS HOUR3 MIN9��'
<br />86 pr31 26, 1922
<br />ee. P1ACE OF DEATH
<br />HOSPITAL: � InpeUeM 9D$@ ❑ NutaU�gHamelLTC ❑HoeP�eFedlttY
<br />❑ ERfOutpetlant ❑ Decetlertl'a Home
<br />❑ 004 DoumrlSaedfy)
<br />Bd.CAUNTYOFDEATH �
<br />n
<br />28b. DATE FlLED BY RE613TRAR (Mo., Day, Yr.)
<br />DEC � � 2008
<br />�
<br />HH&61 11/03 {�5pg1)
<br />
|