201403341 - Laserfiche WebLink

Browse

To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Jimmie Dean Perkins 2. SEX f ' Male '» 1 H (Mo., Day, Yr.) N I 'May 25 2 014- ' 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE • Last Birthday (Yn•) 65 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) July 2, 1948 MOS. DAYS HOURS l MANS. 7. SOCIAL SECURITY NUMBER 506 -58 -7584 8b. FACILITY -NAME (If not Institution, give street and number) 344 Redwood Rd 8a. PLACE OF DEATH HOSPITA{, ❑ 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 I Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 344 Redwood Rd 19e. APT. NO. 9f. ZIP CODE 1 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 Lisa London 11. FATHER'S -NAME (First, Middle, Last, Suffix) Francis Perkins 12. MOTHER'S -NAME (First, Middle, Malden Surname) Ethel Van Bibber 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) Yes 08/20/1965 - 09/20/1966 14a. INFORMANT -NAME Lisa Perkins 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) May 28, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Shickley Public Cemetery Shickley 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 CAUSE OF DEATH (See instructions and examples) I To be completed by: CERTIFIER 18. PART I. Enter the chain of events-diseases, Injuries, or complicationsthat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 1 1/2 WEEKS 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) ACUTE MYELOGENOUS LEUKEMIA disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) any, leading to the cause listed on line 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- CondlUons contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: ❑ Not pregnant within past year P El Pregnant time of at o 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 construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. 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 2W 1 Y uz 29a. DATE OF DEATH (Mo., Day, Yr.) May25,2014 >;' 91 ° i <_ 2 O a fc ° U 3 s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) May27,2014 ( 23c. TIME OF DEATH 10:32 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 W and due to the cause(a) stated. (Signature lid Title) M Kenneth Vettel, 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 I 1 3 ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE /JET / - /�� `�„ / L�j(�b ` r tr/L��IJR Ir/l (1pQ�lf/V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I May 29, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN 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. DATE OF ISSUANCE 201403341 STANLEY S COOPER t ' ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HUM,4II SE!! ( $,'' ' i4 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERyICEt r r! CERTIFICATE OF DEATH 05/30/2014