|
To Be CompletedNerified by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Barbara Jo Hutmacher
<br />2. SEX 1. 4
<br />Female
<br />a 3, GATE OF dFp146Mo Osy,Yr.)
<br />July 2, 2013 ,
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />66
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 3, 1947
<br />7. SOCIAL SECURITY NUMBER -
<br />505 -60 -9331
<br />8a. PLACE OF DEATH
<br />HOSPITAL; ❑ Inpatient OTHER;❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ® Decedent's Home
<br />❑ DOA ❑ Other(Specify)
<br />Bb. FACILITY -NAME (If not institution, give street and number)
<br />416 S. Vine Street
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Mead 68041
<br />8d. COUNTY OF DEATH
<br />Saunders
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />81). COUNTY
<br />Saunders
<br />9c. CITY OR TOWN
<br />Mead
<br />9d. STREET AND NUMBER
<br />416 S. Vine Street
<br />9e. APT. NO.
<br />90. ZIP CODE
<br />68041
<br />9g. INSIDE CITY LIMITS
<br />® Yes 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name.
<br />Douglas F Hutmacher
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />Frank Duane Yale
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Merriwyn Irene Pigsley
<br />13. EVER IN U.S. ARMED FORCES? Glve dates of service H Yes.
<br />(Yes, No, or Link.) N
<br />14a. INFORMANT -NAME
<br />Douglas F Hutmacher
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Maxima ❑DOnatlon
<br />❑Cremation ['Entombment
<br />❑Remowl ❑Othar(spselfy)
<br />168. EMBA
<br />SIGNATURE / ` j -
<br />PD
<br />/_J/ .y / G L _%
<br />16b. UCENSE NO.
<br />/g7
<br />16c. DATE (Mo., Day, Yr.)
<br />July 6, 2013
<br />``
<br />•
<br />• d . CEME , MATORY OR OTHER LOCATI • CITY/TOWN STATE
<br />Sunrise Ceme Wahoo Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Pruss -Nabity Funeral Home, 911 N. Linden, PO Box 127, Wahoo, Nebraska
<br />17b. Zip Code
<br />68066
<br />1 C✓ " To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PMT 1. Enter the gbaln of manta • diseases, Injuries, or complications. that directly caused the death. DO NOT enter terminal events such as cardiac tweet,
<br />APPROXIMATE INTERVAL
<br />to edath ..J-t
<br />onset to eth
<br />w
<br />/ 5
<br />respiratory arrest, or ventdeulr abrdNatlon without showing the etiology. DO NOT ABBREVIATE. Enter only on* cause on • line. Mid additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final ,/
<br />disease or condition resulting a) / w ' . ° �s . ,
<br />in death)
<br />DUE TO, OR AS A CONSEQUEN OF: onset to death
<br />Sequentially list a c aPoons, a �'• _ _ _ " p_
<br />arty, leading to the cause listed b) (�- � _\ �1/"C/7
<br />L
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: i , onset death
<br />i
<br />Enter the UNDERLYING CAUSE c) i
<br />i
<br />(disease or injury that initiated
<br />the events resulting in death) DUE TO, 019 AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contrlbuttng to the death but not resulting in the underlying cause given In PART 1.
<br />18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 240
<br />20. IF MALE:
<br />of pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnaM, but pregnant 43 days to 1 year before death
<br />❑Unknown H pregnant within the past year
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY P FORMED?
<br />❑ YES Ia
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY.
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
<br />. a
<br />F"
<br />2 re
<br />o 0z
<br />m V C-
<br />.0
<br />23a. DATE OF DEA (Mo., Day, Yr.)
<br />1 �1 /)
<br />b'
<br />1 > O
<br />£ .. <
<br />o O
<br />u w z
<br />$ ? 8
<br />,+
<br />� U O
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />! / 1 .�1 1 3
<br />23c. TIME OF DEATH
<br />1' `h © m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. To the best of m k
<br />u the ca s
<br />and �r�
<br />J USE
<br />ed d ath occurred at the thne, date and place
<br />stated. i and Title)
<br />24e On the basis of examination andlor investigation, In my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25.010 TOBACCO CONTRIBUTE TO THE DEA ?
<br />❑ YES ❑ NO ❑ PROBABLY KNOWN
<br />28a. HAS ORGAN OR TISSUE TION BEEN CONSIDERED?
<br />❑ YES - NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 26a is NO ❑ YES Z N ?
<br />27. NAME, TITLE AND AOD SS OF CERTIFIER (Type or Print)
<br />Vn�1) 1 (72 G am. f - c a r3 D
<br />P
<br />28a. REGISTRAR'S SIGNATURE -
<br />� ' • " a
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUL 15, 2013
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA�e'Fh�'A - SERVICES - IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBIA �f➢EP I�I �P• HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F•t t /� C RDS. +
<br />,.. S �` !t7 ✓ '= t ..
<br />DATE OF ISSUANCE
<br />JUL 16 2013
<br />LINCOLN, NE
<br />. 60 : in
<br />SIST1TFGIST1
<br />PARTME T Of H ;
<br />EAL 7'H An
<br />BRASKA ',HrJM4N EkVICE5- • • r ,'' *°,'
<br />1
<br />• a • C c'`. P •.
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVI •
<br />,, • • • • • • e . •
<br />CERTIFICATE OF DEATH w • 11 1 1 J
<br />201309165
<br />
|