201506374 - Laserfiche WebLink

Browse

To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Traci Marie Romans 2. SEX ( Female ' ' 3. DATE OF DEATH (Mo., Day, Yr.) December 1, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 44 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) December 1, 1970 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -82 -7253 8b. FACILITY -NAME (If not Institution, give street and number) 4444 S. 60th Road 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 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4444 S. 60th Road re. APT. NO. 9f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ID Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Erin Spencer Romans 11. FATHER'S -NAME (First, Middle, Last, Suffix) Leslie M Schimmer 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Karen J Frauen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Erin Spencer Romans 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE - Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) December 5, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING 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) I To be completed by: CERTIFIER 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: IMMEDIATE CAUSE (Final a) Hepatorenal Syndrome disease or condition resulting onset to death Weeks in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b)Acute Liver Failure With Cirrhosis 1 10 Months any, leading to the cause listed I I line on a. DUE TO, OR AS A CONSEQUENCE OF: r onset to death Enter the UNDERLYING CAUSE c) Alcoholism 1 Years (disease or injury that initiated . the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: d onset to death LAST d) 1 1 I 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Essential Tremor 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20.1F 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 ID 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 construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE .t 1 r I LI i 23a. DATE OF DEATH (Mo., Day, Yr.) December 1, 2014 £ S rc E k ,. E o a i ' W z O B G ~ o 'a o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 5, 2014 23c. TIME OF DEATH I 10:35 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD U u 0 3d To the best of my knowledge, death occurred at the time, date and place S w and due to the cause(s) stated. (Signature and Title) f Kimberly A. Mickels, MD 248.O the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ 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 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE jj _ - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 8, 2014 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH 4/')dp,,�J,L( 1 N SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA5K '' DE RTN 1T OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR; t/IT4 -kk :DRS ' , t DATE OF ISSUANCE 12/10/2014 STATE OF NEBRASKA 201506374 5Th AILEY S COPPER >4S5TA GISTkAR DEPART i De 1 AND LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC 4 j CERTIFICATE OF DEATH ) > :'., ' ,HEffyAN SERVICES, 14 06257