201401467 - Laserfiche WebLink

Browse

STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTtf AND,NUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB6tASKA'DEMRTNENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR -VITAL RORDS. DATE OF ISSUANCE 201401467 "' STANLEY � « FGISTR,4a DEPARTMENT OF HEALTH. AND LINCOLN, NEBRASKA ` HUMAN,,RVICE'S :'r, STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN --' SEFtVi . `'7 * CERTIFICATE OF DEATH 02/11/2014 14 00577 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Orrin Joseph Armatys 2. SEX 4 . Male 3. DATE OF DEATH (Mo., Day, Yr.) F ebruary • 3, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Pasadena, California 5a. AGE - Last Birthday (Yrs.) 70 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 18, 1943 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -52 -3806 8b. FACILITY -NAME (If not institution, give street and number) 4129 Buckingham Dr. 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 4129 Buckingham Dr. 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS 13 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 Ruth Schaaf 11. FATHER'S -NAME (First, Middle, Last, Suffix) Leo J Armatys 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dorothy E Power 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 06/30/1965 - 03/31/1967 14a. INFORMANT -NAME Ruth Armatys 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Patricia R. Curran 16b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) February 8, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 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 onset to death Immediate 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) Cardiac Arrest disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, U b) any, leading to the cause listed on tine 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 - Conditions contributing to the death but not resulting In the underlying cause given In PART I. Mr. Armatys Was In Remission From Stage 3 Esophageal Cancer Treated With Herceptin 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ 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 ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. 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 B W 1 E r E 0 i 23a. DATE OF DEATH (Mo., Day, Yr.) S �g� i i CO ,. a < = W Z O B Z o o v ~ s 24a. DATE SIGNED (Mo., Day, Yr.) February 6, 2014 24b. TIME OF DEATH Approx. 05:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) February 3, 2014 24d. TIME PRONOUNCED DEAD 08:58 AM 8 O 3d. To the best of my knowledge, death occurred at the time, date and place f, and due to the cause(s) stated. (Signature and Title) U.' g 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) Gail VerMaas, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gail VerMaas, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a. REGISTRAR'S SIGNATURE A. /� / 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I February 10, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTtf AND,NUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB6tASKA'DEMRTNENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR -VITAL RORDS. DATE OF ISSUANCE 201401467 "' STANLEY � « FGISTR,4a DEPARTMENT OF HEALTH. AND LINCOLN, NEBRASKA ` HUMAN,,RVICE'S :'r, STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN --' SEFtVi . `'7 * CERTIFICATE OF DEATH 02/11/2014 14 00577