201302172 - Laserfiche WebLink

Browse

To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Robert Elton Wortman 2. SEX °$ w Male 3. DA'EE OF?DEATH (Mo., Day, Yr.) January 25, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Doniphan, Nebraska 5a. AGE • Last Birthday (Yrs.) 89 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 18, 1923 MOS. I DAYS HOURS MINS I 7. SOCIAL SECURITY NUMBER 507 -34 -7160 5b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Wood River 8a. PLACE OF DEATH 11OSPITAI, ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Wood River 9d. STREET AND NUMBER 1208 Marshall Street e. APT. NO. r 9f. ZIP CODE I 68883 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Mary Wetterer 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Wortman 12. MOTHER'S -NAME (First, Middle, Malden Surname) Clara Gilchrist 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or unk.) Yes 12/23/1944 - 04/16/1946 14a. INFORMANT -NAME Mary Wortman 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16a. EMBALMER-SIGNATURE Derek Apfel 16b. LICENSE NO. 1240 16c. DATE (Mo., Day, Yr.) February 1, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE St. Mary's Cemetery Wood River Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See Instructions and examples) To be completed by: CERTIFIER 18. PART 1. Enter the chain of events-diseases, Injuries, or complicationi4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Tines If necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) acute Cerebral Vascular Accident 3 Weeks disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: • onset to death Sequentially list conditions, H b) Chronic Cerebrovascular Disease >10years any, leading to the cause listed line on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Advanced Age (disease or injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the d - -- ` but not resulting in the underlying cause given in PART I. hypertension, Arteriosclerotic Cardiovascular Disease, Alzheimers Dementia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year P ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pen Investigation Sulfide Could determined ❑ 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 1 E d z 23a. DATE OF DEATH (Mo., Day, Yr.) January 25, 2013 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23 b. DATE SIGNED (Mo., Day, Yr.) January 28, 2013 23c. TIME OF DEATH 05:15 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 g 0 9d. To the best of my knowledge, death occurred at the time, date and place 2 E and due to Me cause(s) stated. (Signature and Title) '' a Steven Husen, MD 24e. On the basis of examination and/or Investigation, in my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ®NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Prin Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE x j .. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 29, 2013 Amended STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALA ANQ HUMA ERVICES,71 CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA �. 0A ( j'';QF f A AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 43TAL• 5, ,, . A it DATE OF ISSUANCE 02/12/2013 LINCOLN, NEBRASKA Amended 02/12/2013 Item 13 dates 201302172 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANS CERTIFICATE OF DEATH StgNLEWS rC00 ER pE1 OF ASSSTAISf} • 1300384