201503297 - Laserfiche WebLink

Browse

To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) James Lee Rayback 2. SEX 1 t , /1 Male DATIE 001:548"171 (Mo., Day, Yr.) Apri110 :2010 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Shelton, Nebraska 5a. AGE • Last Birthday (Yrs•) 83 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) September 19, 1926 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -20 -3713 8b. FACILITY -NAME (If not Institution, give street and number) 2508 Cochin 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 Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2508 Cochin 19e. APT. NO. 8f. 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 Barbara Hendrickson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Walter Rayback 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Mary DeVall 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 01/17/1945-08/27/1946 14a. INFORMANT-NAME Barbara Rayback 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) April 12, 2010 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (Seelnstructions 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 onset to death Immediate respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. l Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b)Chronic Lung And Heart Disorders 10 Years any, leading to the cause listed on Inc I 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 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? D 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 ❑ Homidde ❑ 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 S. W I i i Y 0 z 23a. DATE OF DEATH (Mo., Day, Yr.) B Y �g� 1 i k } < = 8 w i O B g p ~ § s 24a. DATE SIGNED (Mo., Day, Yr.) April 14, 2010 24b. TIME OF DEATH Approx. 02:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH I 24c. PRONOUNCED DEAD (Mo., Day, Yr.) April 1 2010 24d. TIME PRONOUNCED DEAD 10:35 AM 8 4 0 9d. To the best of my knowledge, death occurred at the time, date and place 8 3 and due to the cause(s) stated. (Signature and Title) s 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) Lynelle Homolka, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 126a. HAS ORGAN OR ❑ YES ISSUE r • 17 • ATION BEEN CONSIDERED? r 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO (Type or Print) 68802 ¢ I I 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, HYSICIAN ASSISTANT CORONER 5 PHYSICCOUNTY ATTORNEY) Lynelle Homolka, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, r 28a. REGISTRAR'S SIGNATURE R II' �� _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I April 15, 2010 ode STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AIwkMJ ��QQ, THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASjd'I� HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR.JTITA DATE OF ISSUANCE 9T&h11 EY S. C& PER STA1VSfq Tr DE ARTAIEPPIOF LINCOLN, NEBRASKA 14Uh7 N. SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER ` •• !le. fi` rz j �• CERTIFICATE OF DEATH ► , ' , -, 04/16/2010 201503297 S_ ERVICES, IT CERTIFIES Q F H5ALTH AND I ► F IST : �H fkNQ.' O r -' c, .d • • .' * 1001032