201501753 - Laserfiche WebLink

Browse

To be completed by: CERTIFIER 1 1 To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Richard Lee Frauen 2. SEX Male 3. DATE Qf- Dir4TH (Mo., Day, Yr.) °'September 10, 201Q 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE • Last Birthday (Yrs.) 79 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) September 8, 1931 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -30 -4607 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (include Z!p Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1919 W. Louise 19e. APT. NO. 8f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS I O 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 Janice Kay Anderson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Paul Frederick Frauen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dorothy Evelyn Moeder 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 07/17/1951 - 06/16/1955 14a. INFORMANT -NAME Janice Kay Frauen 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) September 10, 2010 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (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 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) Bowel Perforation 5 Days disease or condltlOn resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Metastatic Neuroendocrine Cancer - Unknown Primary Site 4 Years any, leading to the cause listed on One a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (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!. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 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 ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® 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 1 w Y E ?..1 23a. DATE OF DEATH (Mo., Day, Yr.) September 10, 2010 y S 5 W I , " . ° y ° i i n t i 2 w p ~ g Is 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 10, 2010 23c. TIME OF DEATH I 12:23 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 i 0 9d. To the best of my knowledge, death occurred at the time, date and place 2 c and due to the cause(s) stated. (Signature and Title) o r. s Larry L. Hansen, 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? O 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 ORNEY) (Type or Print) 27. NAME, TITLE AND ADDRESS OF (PHYSICIAN, Larry L. Hansen, MD, 3016 West Faidley, Grand SICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE / aZ{Aj, A - A 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I September 29, 2010 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTNRHUM, Afi /,- A I5 RVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB Ri k(# Q A T'ME(VT, o (-IEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO1 VITA �'(, t 2 015 01 1ry 5 3 STANLEY S:. COOPER - iI SSISTAN TE REGISTRAR ; • R,4R TTS TMENT OF HEALTH -,4ND LINCOLN, NEBRASKA II U!t , •� ,•' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERJCE,S • 10 02754 ti DATE OF ISSUANCE 10/06/2010 CERTIFICATE OF DEATH -