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<br />1. DECEDENT'S -NAME (First, Middle. Las , Suffix)
<br />Val Lavonne Pichler
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 28, 2005
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Inavale, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />79
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 7, 1926
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<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
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<br />7. SOCIAL SECURITY NUMBER
<br />508 -24 -4446
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />St. Francis Medical Center
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ) Inpatient Q11 ❑ NursingHome/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent s Home
<br />❑ ID. ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2203 W. 11th St.
<br />9e. APT. NO
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />Ii YES ❑ NO
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<br />Ka
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<br />10a. MARITAL STATUS AT TIME OF DEATH 4 Married ❑ Never Married
<br />❑M arried, but separated 0 ❑Divorced ❑Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name.
<br />Neoma Fay Finch
<br />y
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Lloyd J. Pichler
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Helen B. Harvey
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />(Yes, no, orunk.) WW II 9/30/1943 3/18/1946
<br />14a. INFORMANT-NAME
<br />Neoma F. Pichler
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑Burial ❑Donation
<br />�Cremalion ❑Entombment
<br />❑Removal ❑ Other (Specify)
<br />16a.EMBALMER- SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr. )
<br />April 28, 2005
<br />16d. CEMETERY, CREMATORY OTHER LOCATION CITY /TOWN STATE
<br />R EATORY OR
<br />Central Nebraska Cremation Service Gibbon, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stale)
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE
<br />17b. Zip Code
<br />68801
<br />US CAUSEOF PVEATHIstrtifitilidtiotiVii eif hifil sj a
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<br />18. PART I. Enter the chain of events -- diseases, Injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I
<br />IMMEDIATE CAUSE: I onset to death
<br />IMMEDIATE CAUSE (Final (a) , f / 14 / i:1 , 444 ` C ` di i?/t S
<br />'
<br />! _es
<br />disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />in death) `
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<br />Sequentially list conditions, if ( ! wr r 0 401,eu/�,! f Q I /0 �' / /s
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that Initiated (
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LPSF
<br />(d)
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<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />7 i / ��.�f/1� `
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<br />14 4
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES . ...41-NO
<br />20.1F FEMALE: I
<br />❑Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />latural ❑ Homicide
<br />❑ Accident❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />216. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES NO
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />site, etc. (Specify)
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm,
<br />street, factory, office building, construction
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN SPATE ZIP CODE
<br />7c
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<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />y - -d1
<br />a . ¢
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<br />Eaaz
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<br />2 3d.
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />m
<br />23b. DATE ( $SJGNEDD A (Mo., Day, Yr.)
<br />I - V - or
<br />23c.TIME OF DEATH
<br />®i m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />To the �b of my knowledge,
<br />andY�f the cause(
<br />death
<br />stated.
<br />/
<br />occur ed at the time, date and place
<br />5 gnature and Title) • /
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title ) •
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES �O ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES �(Q7 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES KIJO
<br />27. NAME, TITL AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY'ATTORNEY) (Type or Print) (r
<br />David Colan M.D. 729 N. Custer, Grand Island, NE 68803
<br />•
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
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<br />201300/00
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />HHS -61 11/03 (55061)
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