201406681 - Laserfiche WebLink

Browse

To be completed by: CERTIFIER -1 1 To be completed/veNfied by: FUNERAL DIRECTOR 1 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Harold Cody Medlen 2. SEX Male 3. DAT`OF DEATH pl o., Day, Yr.) February 14, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH O'Neill, Nebraska 5a. AGE - Last Birthday (Yrs.) 81 5b, UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH,(Jlo., Day, Yr.) November 4, 1929 MOS. DAYS HOURS MINS." 7. SOCIAL SECURITY NUMBER 508 -30 -4335 8b. FACILITY -NAME (If not Institution, give street and number) Nebraska Heart Hospital 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 0 ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68526 8d. COUNTY OF DEATH Lancaster 9a. RESIDENCE-STATE Nebraska Nebraska COUNTY I Hall 9c. CITY OR TOWN Grand Island STREET AND NUMBER 543 E. 19th e. APT. NO. re. 9f. ZIP CODE 68801 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 Jacqueline Reichstein 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Herman Medlen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Myrtle Mae Doolittle 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Jacqueline Medlen 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Michael B. Williams 16b. LICENSE NO. 1083 16c. DATE (Mo., Day, Yr.) February 18, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Sunset Memorial Gardens Hastings 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 1. Enter the chain of events- diseases, Injuries, or compllcations directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 24 Hours 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) Aspiration Pneumonia disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) lschemic Cardiomyopathy Years any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Renal Failure Days (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART 11. 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 ® 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 if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident 0 Pending Investgation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES 1E1 NO 21d. WERE AUTOPSY FINDINGS AVAILABL 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 l' % 1 i 8 6 o '13a. DATE OF DEATH (Mo., Day, Yr.l February 14,2011 E 3 a 8 Y < _ a, rc O W 8 z p '" o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) February 16, 2011 23c. TIME OF DEATH I 04:25 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and platy S and due to the cause(s) stated. (Signature and Title) 2 James H. Wudel, MD 24e. On the basis of examination and/or investigation, In my opinion death occurred at tin 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 P 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, James H. Wudel, MD, 7440 S 91st St, Lincoln, 26a. HAS ORGAN OR ® YES HYSICIAN ASSISTANT Nebraska, 68526 ISSUE DONATION BEEN CONSIDERED? ■ COR • ` COUNTY A 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ® NO ORNEY) (Type or Print) 128a REGISTRAR'S SIGNATURE 286. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 17, 2011 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A {* lAUMAN THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE8R4; SKA:11 4R.MMEN HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT`AL DATE OF ISSUANCE $TANEEY .. CO:OPER ASSISTANT STATE REQ STR4R DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA ! )UNY.t{1V S R1/I , STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES: CERTIFICATE OF DEATH ` 02/17/2011 201406681 RVICES, IT CERTIFIES F HEALTH AND