201309491 - Laserfiche WebLink

Browse

To be completed/verified by FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Harold John Kinkle 2. SEX / Male ‘3, DATTEO7 DEATH (Mo., Day, Yr°) -September 12 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Madison County, Nebraska 5a. AGE - Last Birthday (Yrs.) 85 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) November 3, 1927 MOS. DAYS HOURS MINS. I 7. SOCIAL SECURITY NUMBER 507 -22 -6604 8b. FACILITY -NAME (If not Institution, give street and number) 4010 Greenwood 8a. PLACE OF DEATH HOSPITAI. ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatlent ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 8c. CITY OR TOWN I Grand Island 9d. STREET AND NUMBER 4010 Greenwood 9e. APT. NO. 19f. ZIP CODE 1 68803 19g. INSIDE CITY LIMITS 1 ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Manled, but separated ® Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Dorothy Anderson 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Kinkle 12. MOTHER'S -NAME (First, Middle, Malden Surname) Gratha Krohn 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 04/12/1946 - 09/30/1947 14a. INFORMANT -NAME Katherine Kay Holster 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 16c. DATE (Mo., Day, Yr.) September 16, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 15. 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 onset to death 1 Year respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Metastatic Transitional Cell Cancer Of Bladder disease or condition resuMing In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) any, leading to the cause listed line on a DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (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 - Condition contributing to the death but not resulting In the underlying cause given In PART 1. Prostatic Adenocarcinoma 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of dears ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown M pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be 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 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE .S E g 1 YS E 23a. DATE OF DEATH (Mo., Day, Yr.) September 12, 2013 0 g 1 I C > E d < z B = w z O e O ~ g ; 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 13, 2013 1 23c. TIME OF DEATH 03:48 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 9d. To the best of my knowledge, death occurred at the time, date and place 2 and due to the cause(s) stated. (Signature and Title ) o '" 2 William Landis, 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 cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO 0 PROBABLY ® UNKNOWN 1 26a. HAS ORGAN OR 0 YES ISSUE DONATION BEEN CONSIDERED? f77 NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, • : 03 28a. REGISTRAR'S SIGNATURE /j) /� _ 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) September 17, 2013 ° ° WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALINAN ,I -NMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA pP OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO VITAL REcC5Dr,S., 1 DATE OF ISSUANCE 09/19/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA 201309 - :S-1NLEY_S. COOPER. : ASST 4 r 5 A REGI$;T ' -=DEPA it b WEALTH_A4D ,. +'. .HUMAN SF VICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC.S j; 1 CERTIFICATE OF DEATH (, 13 03956