201400684 - Laserfiche WebLink

Browse

To be completedNerified by: FUNERAL DIRECTOR 1 1. DECEDENT'S•NAME (First, Middle, Last, Suffix) Lloyd Edward Romine 2. SEX '- `' ' Male 3. DATE OF DEATH (Mo., Day, Yr.) June 21, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Palisade, Nebraska 5a. AGE • Last Birthday (Yrs.) 86 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) September 11, 1926 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -24 -0277 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ 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 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 422 S Woodland Dr 19e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Phyllis M Sailors 11. FATHER'S -NAME (First, Middle, Last, Suffix) Jesse Beauford Romine 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Margaret Jeffries 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 11/14/1944- 07/13/1946 14a. INFORMANT -NAME Phyllis M Romine 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ❑ Cremation El Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Kevin Wood 16b. LICENSE NO. 1325 16c. DATE (Mo., Day, Yr.) June 25, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 i CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART I. Enter the chain of events - -diseases, Injuries, or complications-that directly cawed the death. DO NOT enter terminal events such as cardiac arrest, . APPROXIMATE INTERVAL onset to death < 1 Week - 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) Respiratory Failure disease or condition resulting - In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b)Aspiration Pneumonia <2 Weeks any, leading to the cause listed line a. on DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Cerebral Vascular Accident > 1 Month (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. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ❑ Not pregnant within past year 0 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 0 Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Co u determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. 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 k 5 I 1 >. 8 a o 23a. DATE OF DEATH (Mo., Day, Yr.) June 21,2013 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) J 24, 2013 23c. TIME OF DEATH I 03:30 AM 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best Of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) '' s Jennifer L. Brown, 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? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable H 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 I 28a. REGISTRAR'S SIGNATURE j 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 1, 2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND'HUMM4I N IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT PF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR - VITAL RECORDS. A s ► Z t ' t t DATE OF ISSUANCE 07/15/2013 LINCOLN, NEBRASKA 201400684 -STANLEY S. C A$SISTIArA RRGISTR4R.* L EPAP2T - O# f?E LTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES.. '' r^ !_ • • f CERTIFICATE OF DEATH �' f I 13 02770