201401839 - Laserfiche WebLink

Browse

To be completedNerified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) William E Engle 2. SEX Male 3.' DATE bF DEATH (Mo., Day, Yr.) January 23, 2010 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 69 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 19, 1940 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -38 -1150 8b. FACILITY -NAME (If not Institution, give street and number) 3011 North Webb Road 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 3011 North Webb Road 9e. APT. NO. 9f. ZIP CODE 68803 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 Jeannine Mae Bruhn 11. FATHER'S -NAME (First, Middle, Last, Suffix) Robert Engle 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Winsome Gorman 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Jeannine Mae Engle 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Derek Apfel 16b. LICENSE NO. 1240 16c. DATE (Mo., Day, Yr.) January 29, 2010 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) 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 I. Enter the chain of event •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) Myocardial Infarction disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Long -term Coronary Artery Disease 20 +years 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 - Conditions contributing to the death " but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: 1:1 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 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.) I 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE S I I Y o u z 23a. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) March 10, 2010 24b. TIME OF DEATH Approx. 01:00 PM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) January 23, 2010 24d. TIME PRONOUNCED DEAD 04:20 PM u 8 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 8 and due to the cause(s) stated (Signature and Title) o f 24e. On the basis of examination and /or investig tion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Lynelle Homolka, Hall Deputy County Attomey 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? I ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OFCERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Lynelle Homolka, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 126a. REGISTRAR'S SIGNATURE � I W V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 11, 2010 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH 'f VICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKIrDfflARITVILVT.MIE AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VfT4h kECORF•Q• • . DATE OF ISSUANCE 03/12/2010 LINCOLN, NEBRASKA S1 NtEY S Qf, .1ER 2D14018,19 D RTfENTO) k �D HUMf1N'2 R,VICES „ STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ' ; - • .v/.1 CERTIFICATE OF DEATH \ _ - 10 00659