|
To be completed/verified by: FUNERAL DIRECTOR
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Marsha Ann Trujillo
<br />2. SEX '
<br />Ferrate . •'°
<br />1 DATE OF DEATH (Mo., Day, Yr.) '
<br />November 11, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />North Platte, Nebraska
<br />Sa. AGE - Last Birthday
<br />(Yrs.)
<br />63
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />December 12, 1950
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -66 -4025
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />8a. PLACE OF DEATH
<br />HOSPITAL, ® Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />0 ER/Outpatient 0 Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2809 Dallas Ave
<br />e. APT. NO.
<br />C
<br />` 9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />0 YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />O Married, but separated U Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Henry Roy Trujillo
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Theodore Fred Cook
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Patricia Joann Peters
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Henry Roy Trujillo
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />o Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER- SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />November 17, 2014
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />1 7b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />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, r APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibdllation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Intra abdomenal Catastrophe
<br />disease or condition resulting
<br />onset to death
<br />24 Hours
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Sequentially Ust conditions, if b) Infarcted Intestine t 24 Hours
<br />any, leading to the cause listed I
<br />I
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Eder the UNDERLYING CAUSE C) I
<br />(disease or injury that Initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST d) e
<br />I
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Chronic Pancreatitis,Chronic Pain
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES 0 N
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />Pregnant at time of death
<br />0 o Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver /Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES 0 N
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />ssaa COMPLETE CAUSE OF DEATH?
<br />f'YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) I22b.
<br />TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />YES 0 NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />r te
<br />W
<br />1 s r
<br />E v Z
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 11, 2014
<br />�''gi
<br />4 E G Y
<br />E G� o Q Z J
<br />` z O
<br />B g §
<br />' 'a
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 18 2014
<br />23c. TIME OF DEATH
<br />I 08:09 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />-.1 O 3d. T o the best of my knowledge, death occurred at the time, date and plan
<br />antl due to the causes) stated. (Signature and TRIO
<br />l Ryan D. Crouch, DO
<br />2h. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tide)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO ❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand
<br />Island, Nebraska, 68803
<br />1285 REGISTRAR'S SIGNATURE -
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 20, 2014
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH'AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAibEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQI VITAS.' RECORDS:
<br />DATE OF ISSUANCE
<br />11/24/2014 201407952 :STAN) Y S
<br />:ASSISTANT Tj
<br />DEPARTMENT OF"HEALT.H.AND
<br />•`HUMAN SERVICES
<br />OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES, ' ' A
<br />CERTIFICATE OF DEATH
<br />LINCOLN, NEBRASKA
<br />14 05954
<br />
|