201402028 - Laserfiche WebLink

Browse

To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Barbara Anne Zulkoski 2. SEX '' ! , ' " ^ Female 3 . ' DA T EO F ,)EATH (Mo., Day, Yr.) `,. •Noverttber18, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Grand Island, Nebraska 5a. AGE - Last Birthday MO 48 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) March 24, 1964 I DAYS HOURS MINS. I 7. SOCIAL SECURITY NUMBER 505 -82 -5736 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 813. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) Sc. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH I Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN I Alda 9d. STREET AND NUMBER 5500 South 60th Road 19e. APT. NO. I 9f. ZIP CODE 68810 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 Martin An hony Zulkoski 11. FATHER'S -NAME (First, Middle, Last, Suffix) Wayne Meier 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Sharon Denman 13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Martin Anthony Zulkoski 1413. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) November 21, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Alda Cemetery Alda 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) I To be completed by: CERTIFIER 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 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: onset to death IMMEDIATE CAUSE (Final a) Thymoma, Malignant And Metastatic 2 Years disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: - onset to death Sequentially list conditions, N 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 - Conditions contributing to the death but not resulting in the underlying cause given In PART I. Abnormal MRI Brain, Pulmonary Hypertension Due To Illness, Seizure Due To Illness 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 it pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 0 Suicide 0 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 .6 5 1 i 0 21 23a. DATE OF DEATH (Mo., Day, Yr.) 18, 2012 a Y t 11 k ,. a a.< o F i g E o ~ 3 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH _November 23b. DATE SIGNED (Mo., Day, Yr.) December 3, 2012 23c. TIME OF DEATH ` 04:55 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 9 d. To the best of my knowledge, death occurred at the time, date and place 0 2 a and due to the causes) stated. (Signature and Title) s Kimberly A. Mickels, 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? ❑ 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 Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /]lam A f �y `�, _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 3, 2012 DATE OF ISSUANCE WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH,AND ° I - TUMAA( SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT Of HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR-VITAL RECORDS," - ) •' t \TT i •- 1 'TANt EY AS ISTA d EPARTM s d LINCOLN, NEBRASKA F-UIVIAN SE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES, • • C (f CERTIFICATE OF DEATH t ` ;s* • • 12/05/2012 STATE OF NEBRASKA 201402028 I t GISTRAR CtH AND 12 04539