|
To be completed by: CERTIFIER To be completed/verified by: FUNERAL DIRECTOR
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Gerald Dean Frederiksen
<br />`2 /SEe :• tJ f? f,S
<br />Male i ;, /, :
<br />-GATE OrbEATH (Mo., Day, Yr.)
<br />',' Feb Uarr42, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Merrick County, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />85
<br />5b. UNDER 1 YEAR
<br />5c. tkrogR 1.,DAY
<br />6.'DAT,E'OF BIRTH (Mo., Day, Yr.)
<br />''' "-
<br />May 27,1928
<br />MOS.
<br />DAYS
<br />HOURS
<br />MIN$ -
<br />7. SOCIAL SECURITY NUMBER
<br />550 -32 -1898
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<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 />I Grand Island
<br />9d. STREET AND NUMBER
<br />680 S Shady Bend Road
<br />re. APT. NO,
<br />9f. ZIP CODE
<br />I 68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />June Eastman
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Guy Frederiksen
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mabel Heinemann
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 06/23/1954- 06/21/1956
<br />14a. INFORMANT -NAME
<br />June Frederiksen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />18a. EMBALMER- SIGNATURE
<br />Mike McQuiston
<br />16b. LICENSE NO.
<br />1129
<br />16c. DATE (Mo., Day, Yr.)
<br />February 17, 2014
<br />lad. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Giltner Cemetery Giltner Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Higby McQuiston Mortuary, Inc., 1404 L Street, PO Box 204, Aurora, Nebraska
<br />17b. Zip Code
<br />68818
<br />CAUSE OF DEATI{(Seeinstructions and examples)
<br />111. PART I. Enter the chain of events -- diseases, Injuries, or compiications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />3 Days
<br />respiratory arrest, or ventricular fibrillation 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) Sepsis
<br />disease or condition resulting
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: - onset to death
<br />Sequentially list conditions, If b) Diffuse Vascular Disease
<br />any, leading to the cause listed
<br />online a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days tot year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. 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 ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />A' 1
<br />1 61 21
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 12, 2014
<br />a
<br />O
<br />E iii < Z
<br />O
<br />s z
<br />p
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />February 17, 2014
<br />23c. TIME OF DEATH
<br />I 01:41 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />S Je 0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />o La '" 2 Richard Fruehling, MD
<br />24e. On the basis of examination and /or investig lion, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />I ❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE /)1� /��
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />February 18, 2014
<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 NEBRASKA DE''ARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RBtARD,S,
<br />DATE OF ISSUANCE
<br />02/19/201
<br />LINCOLN, NEB
<br />STATE OF NEBRASKA
<br />201501676 : sfAnri c 0 : °FM � °f
<br />SSISTANZS,TATE REGIsTPAR
<br />- be/ART FF HEALTH;s1,Nt
<br />NEBRASKA ; VUMA' '`'I " sr :: <3 •
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SE RVICES = ; '
<br />CERTIFICATE OF DEATH r ' ,� f' "
<br />•
<br />14 00756
<br />
|