201406382 - Laserfiche WebLink

Browse

1 To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Joseph John Toczek 2. SEX ' Male 3. DATE OF DEATH (Mo., Day, Yr.) September 20, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup City, Nebraska 5a. AGE - Last Birthday (Yrs.) 71 513. UNDER 1 YEAR 5c. UNDER 1 DAY- ° 6: DATE OF BIRTH (Mo., Day, Yr.) January 12, 1943 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 - 50-8078 Ba. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ® ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Coda) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY I Hall 9c. CITY OR TOWN Grand Island STREET AND NUMBER 1603 Bass Road re. e. APT. NO. 9f. ZIP CODE 1 68801 9g. INSIDE CITY LIMITS I ® 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 Darlene M Baran 11. FATHER'S -NAME (First, Middle, Last, Suffix) Joseph J Toczek 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Helen Augustyn 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) Yes 01/09/1961 - 12/10/1963 14a. INFORMANT -NAME Darlene M Toczek 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) September 26, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OFDEATH (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 20 Years 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) Asthma disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Coronary Artery Disease l 20 Years any, leading to the cause listed I on line a. i DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Hyperlipidemia 120 Years (disease or injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. Cancer Of Pancreas 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 El Unknown if pregnant within the past year 21a. MANNER OF DEATH (ZI 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 ID NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. 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 a 5 1 z r Fa i; z 23a. DATE OF DEATH (Mo., Day, Yr.) September 20, 2014 S 1 I E k Y t < c W pp .S O ~ s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 24, 2014 23c. TIME OF DEATH I 06:10 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD " u O 3d. To the best of my knowledge, death occurred at the time, date and place g c and due to the cause(s) stated. (Signature and Title) 2 Gary Settje, 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 Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 ► 1 28a. REGISTRAR'S SIGNATURE' 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 29, 2014 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 09/30/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA STANLEY ,5; COOPER. ASSISTANT STATE REGISTRAR DEPART .7 #Nt.OP HEALTI --LAND HUNtA1V SEOVPCES' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 201406382 14 04892