201406087 - Laserfiche WebLink

Browse

To be completed by: CERTIFIER 1 1 To be completed/verifled by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Marie Lillian Sekora 2. SEX." Female , 3. DATE OF DEATH (Mo., Day, Yr.) t 'September 4, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Clay County near Spring Ranch, Nebraska 5a. AGE - Last Birthday (Yre•) 91 5b. UNDER 1 YEAR 5c. UNDER 1 DAY ,6. DATE OF BIRTH (Mo., Day, Yr.) September 25, 1922 MOS. DAYS HOURS ` MINS. 7. SOCIAL SECURITY NUMBER 507 -24 -6564 8b. FACILITY -NAME (If not Institution, give street and number) Mary Lanning Healthcare 8a. PLACE OF DEATH )1OSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Hastings 68901 8d. COUNTY OF DEATH Adams 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 1527 Windsor Rd r e. APT. NO. 9f. ZIP CODE I 68801 9g. INSIDE CITY LIMITS M 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 Edward Sekora 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Lipovsky 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lillian Wolfe 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Marlene Cooley 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (specify) 16a. EMBALMER - SIGNATURE Patricia R. Curran 18b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) September 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 L 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) Congestive Heart Failure N/a disease or condition resulting 1n data) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) • any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) i (disease or injury that initiated I . the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST 1 d) t 1 18. PART II.OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ea 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 H pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide I] Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 0 Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El 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 .2 W F I r a: E u z 23a. DATE OF DEATH (Mo., Day, Yr.) September 4, 2014 i; s 1 i r l a.« c u C W B K 8 8 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 5, 2014 23c. TIME OF DEATH 01:20 PM 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD .:c 3d. To the best of my knowledge, death occurred at the time, date and place 2 w a nd due to the cause( s) stated. ( g nature and Tltia ) Si le f David J. Schram, MD 24e. On the basis of examination and/or Investigation, in my opinion death occulted at the time, date and place and due to the cause(*) stated. (Signature and Tills) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES IZI NO 25b. WAS CONSENT GRANTED? Not Applicable H 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Prin David J. Schram, MD, 1021 W 14th St., P.O. Box 968, Hastings, Nebraska, 68902 1 28a. REGISTRAR'S SIGNATURE - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 8, 2014 4 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 09/09/2014 201406 STANLEY.Ss .COOP €€R ASSISTANT STATE' REGISTRAR DEPARTMENT OF- HEALTH AND. LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH , • '14 04458