201502901 - Laserfiche WebLink

Browse

To Be Completed/Verified by: FUNEItANBIRECTBR- --____ 1. DECEDENTS -NAME (First, Middle, Last. Suffix) James Albert Kunze 2. SEX - Male 3. DATE OF DEATH (Mo.,Day,Yr.) January 27, 2009 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska 5a. AGE -Last Birthday (Yrs.) 68 6b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) June 12, 1940 MOB. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -52 -4541 8.. PLACE OF DEATH HOSPITAL: ❑ Inpatient OM& ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Ave. 3621 Laura -6eee - ❑ ER/Outpatient RI Decedent's Home ❑ DOA ❑ other(Specify) 6c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 91. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND 01`MBER 3621 Laura A -E e n 9e. APT. NO. 9r. ZIP CODE 68803 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) H wife, give maiden name. Carolyn Beed 11. FATHERS-NAME (First, Middle, Last, Suffix) Albert Kunze 12. MOTHER'S -NAME (First, Middle, Malden Surname) Twila Weber 13. EVER IN U.S. ARMED FORCES? Give dens of service if Yes. (Yes, No, or link.) Yes 04/12/1962 04/10/1954 14a. INFORMANT -NAME Carol n Kunze 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION IN Buda ❑o.n.tien ['Cremation ❑Entombment ❑ Removal ❑Olhanse. rt yEMMBALNJER.SIGNA ^,,,� 11 u I P /f .t)LQ►1fO ) 16b. LICENSE NO. >(CJ`1 O 16c. DATE (Mo., Day, Yr.) January 31, 2009 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Rose Hill Cemetery Palmer Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Jacobsen - Greenway Funeral Home, 411 0 Street, PO Box 112, St. Paul, Nebraska 17b. Zip Code 68873 1 To Be Completed by: CERTIFIER CAUSE OF DEATH (See instructions and examples) 15. PART 1. Enter the cue d.wnu - disea.ss, injuries, or complication. -that dlreedy caused the death. 00 NOT enter terminal events such as cardiac meat, APPROXIMATE INTERVAL respiratory arrest. or ventricular Dbriastion without showing the etiology. DO NOT ABBREVIATE. Enter only one sup an a tine. Add additional lines B neaeeary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final / ./ � � / 1 Y In dash) In disease t or condition resulting .) 1."" c G. !► / mn� Wti'r/ DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially Ilst conditions, R b) any, leading to the cause listed on line 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) 15. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART!. CnA- c$A44'IL 7 AA ft ` / (•S C4 L 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES R 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 I pregnant within Use past year 21a. MANNER OF DEATH ( itural ❑ 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 1E5NO 21d. WERE TOTEY 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. N0. CITY/TOWN STATE ZIP CODE rtl } E�i s F° t: 23a. DATE OF DEATH (Mo., Day, Yr.) I - 0 7.05 Z � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH f11 23b. DATE SIGNED (14o., Day, Yr.) 0 3 -09 23c. TIME OF DEATH 5:i A m y O y< 24c. PRONOUNCED DEAD (Ma., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the beet of my knowledge, death occurred at the time, date and place and d to the cause(s) stated. ((91 stunt and Title) 8 W C 2 g p V t'1 O 224ee. On the basis of examination and/or Investigation, In my opinion death occurred at the tine, date and place and due to the cause(s) stated. (Signature and Tide) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES c ria0 ❑ PROBABLY ❑ UNKNOWN 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 'f.NO 28b. WAS CONSENT GRANTED? Not Applicable 11265 N NO ❑ YES'NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) , 4v//7 (OL ' M/7 - 7 q %/ ( T d2 - 6 ,e'p /s2,i' D ,PE XVV3 J 28a. REGISTRAR'S SIGNATURE i . J (fit. A 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) FEB 9 2009 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF, HEALTPI 4)Vb'HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEQRA$I*Ai DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY .FO VITAL;.RECORDS. STANLEY S. COOPER ASSISTANT STATE I:EGISTRAR DEPARTMENT OF 1IBALTA AND 'tiUMAN SERVICES DATE OF ISSUANCE FEB 11 2009 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERNI 201502901