|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDIIUMANSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI TIC S SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />MAY 0 5 2006
<br />LINCOLN, NEBRASKA
<br />2 01301262
<br />TIFICATE OF DEATH
<br />TANLEY S.
<br />ASSISTANT STATE- REGISTR#i?
<br />HEALTH AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPP„ORT
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Allen Louis Buettner
<br />2. SEX
<br />Male
<br />3. Art 'V DEAfr ( A. c?e '4r
<br />April 30, 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, 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 />July 21, 1926
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />;..
<br />7. SOCIAL SECURITY NUMBER
<br />506 -22 -5759
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient QOM IursingHome/LTC 0 Hospice Facility
<br />❑ ER /Outpatient ❑ Decedent's Home
<br />❑ 1:04 ❑ Other(Specify)
<br />fip
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />Grand Island Veterans Hcane
<br />2300 W. Capital Avenue
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, Nebraska 68803
<br />8d. COUNTY OF DEATH
<br />Hall County
<br />psi
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Alda
<br />9d. STREET AND NUMBER
<br />2360 S. Engleman Rd.
<br />9e. APT. NO
<br />9f. ZIP CODE
<br />68810
<br />9g. INSIDE CITY LIMITS
<br />❑ YES g NO
<br />'
<br />10a. MARITAL STATUS AT TIME OF DEATH tio Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name.
<br />Martha Lindley
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Louis Buettner
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Dora Wiese
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If yes.
<br />(Yes, no, orunk.) Yes: 10/30/1944 11/14/1946
<br />14a. INFORMANT -NAME
<br />Martha Buettner
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />, y idA�
<br />15. METHOD OF DISPOSITION
<br />❑Burial ❑Donation
<br />OrCremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr. )
<br />May 1, 2006
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br />Westlawn Memorial Park Crematory Grand Island, NE
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) -
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE.
<br />17b. Zip Code
<br />68801
<br />�' '� ,yn ib d"°'" rr. Y *a °
<br />y '
<br />a 1:?
<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.
<br />i
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final (a) Cardiorespiratory Arrest ; Immediate
<br />diseaseorcondition resulting DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />in death)
<br />Sequentially list conditions, If ( b ) Congestive Heart Failure - I j 1 Year
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />sn line a.
<br />Enter the UNDERLYING CAUSE
<br />(dlseaseorinjurythatinitfated (c) Ischemic Myocardiopathy ) 1 Year
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LAST
<br />(d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART. I.
<br />Severe Peripheral Vascular Disease affecting both lower
<br />extremities; CA of Prostate; CRF; HTN.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ):;;S; NO
<br />ri
<br />/
<br />,, V e
<br />..,a
<br />':'..
<br />m m
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />1 :1 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 oast year
<br />21a. MANNER OF DEATH
<br />'Natural ❑ Homicide
<br />❑ Accident Pending Investigation
<br />❑Suicide ❑Could not be determined
<br />21 b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />YES A NO
<br />21d. 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 />22c. PLACE OF INJURY -At home, farm,
<br />street factory, office building, construction
<br />.
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />£
<br />-
<br />2
<br />gE-
<br />o 0,o
<br />m ,
<br />o c
<br />~ Q
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 30, 2006
<br />a )-
<br />; a Q
<br />d i r
<br />naa }
<br />8 E . "
<br />z z
<br />a Q o
<br />~ e re 0
<br />` o
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />m
<br />2 � DATE SIGNED (Mo., Day, Yr.)
<br />May 1, 2006
<br />23c.TIME OF DEATH
<br />2 -:30 A m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />-
<br />knowledge, occur e and 23d. To the best of my know death r ed at the time, date place
<br />and due to the cause(s) stated. (Signatu e and Title) i'
<br />/11// .. '...
<br />iv
<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 ) y
<br />25. DID TOBACCO USE CONTRIBUT O THE DEATH?
<br />❑ YES ❑ NO ❑ PROBABLY UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 00
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />I )' -',
<br />".`
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />M.A. Tompkins, M.D., Grand Island Veteran Grand Island, NE 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />Ak44( 1'`
<br />29b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />SWAY 4 2006
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDIIUMANSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI TIC S SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />MAY 0 5 2006
<br />LINCOLN, NEBRASKA
<br />2 01301262
<br />TIFICATE OF DEATH
<br />TANLEY S.
<br />ASSISTANT STATE- REGISTR#i?
<br />HEALTH AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPP„ORT
<br />
|