|
1
<br />C1
<br />0.
<br />E
<br />O
<br />U
<br />r-
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND F(U,MAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ;VITAII,A bb$
<br />DATE OF ISSUANCE
<br />AUG .31 2015
<br />LINCOLN, NEBRASKA
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />1. DECEDENTS -NAME (Fist, Middle, Lest, Suffix)
<br />Jane M Kamper
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ashton, Nebraska
<br />7. SOCIAL SECURrIY NUMBER
<br />- - 508 - 30 -4771
<br />8b. FACAITY- -NAME (E not MetNntlon, give street and number)
<br />Tiffany Square Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />98. RESIDENCE -STATE
<br />Nebraska
<br />M. STREET AND NUMBER
<br />1421 Hancock Ave.
<br />10a. MARITAL STATUS AT TIME OF DEATH Ell Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Sufis)
<br />Peter Waskowiak
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yee, No, or Unk) N
<br />15. METHOD OF DISPOSITION
<br />®aedal ❑heathen
<br />❑o m ie. 0 Entombment
<br />❑Removal 00thedepacMy)
<br />Sb. COUNTY
<br />Hal)
<br />18x. EMBALMER-SIGNATURE
<br />lad. CEMETERY, CREMATORY 011 OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Sheet, City or Town, State)
<br />Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />,a FART
<br />L Em.run SMbrdaveetr. CAUSE OF DEATH (See Instructions and examples)
<br />mspimt E meet. o dalcnlar t' dise I N s or complications. that dincey caused the death. DO NOT enter krminal events each as cardiac amat,
<br />owing the eDdlegy. DO NOTAINIREVIATIL Setts enIy ow cause en a line. add additional Ones a etweesaty,
<br />£ 1MMEDIA ' AUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition reaultng a)
<br />In death)
<br />DUE TO,9g Ail A ,� NSEQUENCE OF: 45f2/<
<br />Sequentially list conditions, If
<br />any, leading to t cause listed b)
<br />on tine e. DUE TO, OR ASA CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE 0)
<br />(disease or injury that initiated
<br />the events resulting in death) DUE TO, OR ASA CONSEQUENCE OF:
<br />LAST
<br />d)
<br />'1120. IF FEMALE:
<br />['Not prevent 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 to 1 year before death
<br />❑Unknonm if pregnant wihin the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />221. LOCATION OF INJURY- STREET a NUMBER, APT. N0.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Feb. 1, 2011
<br />311. DATE SIGNED (Mo., Day, TO
<br />Febru
<br />3d. To the
<br />and d
<br />DID TOBAC r 'E CONTRIBUTE TO THE D
<br />❑ YES NO ❑ PROBABLY
<br />STATE OF NEBRASKA
<br />201506103
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTI I AND HUMAN SERVtC
<br />TI • .
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />80
<br />1, 2011 7 :58
<br />Ob. UNDER 1 YEAR
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HSb8ETa1. ❑ Inpatient
<br />❑ ERIOutpatient
<br />❑ DOA
<br />9c. CITY 011 TOWN
<br />Grand Island
<br />HOURS
<br />8d. COUNTY OF DEATH
<br />Hall
<br />1011. NAME OF SPOUSE (First, Middle, Last, Suffix) H wire, live midden name,
<br />Robert D Kamper Surname) 12. MOTHERS -NAME (First, Middle, Malden Surname)
<br />Anna Lewandowski
<br />14a. INFORMANT-NAME
<br />Robert D Kamper
<br />1a. MANNER OF DEATH
<br />f tarsi ❑ Homicide
<br />A ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be detemihed
<br />14b. LICENSE NO. 16x. DATE (Mo., Day, Yr.)
<br />/Y.5 Feb. 4, 2011
<br />CRYR'OWN
<br />Grand Island
<br />QIHER: J Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other(Specify)
<br />'Q18. PART II HER SIG ANT CONDmONS- Condlrons contributing to the death but not reaWtlng In Me underlying cause given In PART L
<br />2111. IF TRANSPORTATION INJURY
<br />0 DdverIOperator
<br />❑ Passenger
<br />❑ Pedestrian ❑ Other (Specify)
<br />STANLEY S. COOPER
<br />ASSISTANT-STATE REGIST4R •<
<br />DEPAEN�T'AI-HEAL,TH ;AND
<br />HUMAN SERVICES -"
<br />PAINS.
<br />April 4, 1930
<br />Husband
<br />onset to death
<br />A WAS MEDICAL EXAMINER
<br />ORCORONEgCONTACTED?
<br />❑ YES �i' NO
<br />41c. WAS AN AUTOP PERFORMED?
<br />❑YES IYN0
<br />21d. W Y FN
<br />WERE AUTObSDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />OYES 13 NO
<br />1 2211. TIME OF INJURY 22c. PLACE OF INJURY -At home, fans, street, factory, once
<br />building, construction sib, eta. (Specify)
<br />m
<br />230. TIME OF DEATH
<br />CITY/TOWN
<br />am
<br />my knowledge, death occurred at the time, data and place
<br />a (s) eta 1. SI attire and Title)
<br />24a. DATE SIGNED (Ma., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />28a. HAS ORGAN OR TISSUE DOIATION BEEN CONSIDERED?
<br />❑ yea Moto
<br />3. Dit OF DEATH (Mo.,Day,Y, )
<br />February 1, 2011
<br />& DATE OF BIRTH (Mo., Day, Yr.)
<br />14b. RELATIONSHIP TO DECEDENT
<br />24b. TBIIE OF DEATH
<br />APPROXIMATE INTERVAL
<br />4 onset todeathh /e
<br />iens to death
<br />onset / d ap
<br />STATE ZIP CODE
<br />24d. TIME PRONOUNCED DEAD
<br />1 m
<br />24e. On t basis of examination a dlor Investigation, In my opinion death occnrisd
<br />at M Erns, ne, dab and place and duo to the causerie) stated. (Signature end Title)
<br />_( OyyN 2811. WAS CONSENT GRANTED? 1
<br />. 27. NAME, TITLE AND ADDRESS OF CERTIFIE INCMAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) n(t' pporaWa t 28s Is NO ❑ YES 12".(0 John A Wagoner MD 800 Alpha St Grand Island NE 68803 (TrP °orPrmt)
<br />28a. REGISTRAR'S SIGNATURE
<br />2811. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />FEB 3 2011
<br />s {782
<br />❑ Hospice Facility
<br />Sg. INSIDE CITY LIMITS
<br />Yes ❑ No
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68803
<br />m
<br />1
<br />
|