201506507 - Laserfiche WebLink

Browse

To be completed /verified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Lois Irene Koepp 2. SEX Female 3. DATE DEATH (Mo., Day, Yr.) July 12, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Big Springs, Nebraska 5a. AGE - Last Birthday (Yrs.) 77 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 9, 1938 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -42 -2873 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Grand Island Village 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 5 Ponderosa Drive 9e. APT. NO. 9f. 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 lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Robert Koepp 11. FATHER'S -NAME (First, Middle, Last, Suffix) Floyd M Clement 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dorothy M Reck 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Robert Koepp 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment 0 Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) July 16, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery 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 u To be completed by: CERTIFIER I I 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, t 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) Acute On Chronic Diastolic Heart Failure disease or condition resulting onset to death Months in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b)Severe Pulmonary Hypertension Years any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Pulmonary Embolism /chronic Thromboembolic Disease Years (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Idiopathic Thrombocytopenic Purpura, Small Bowel Obstruction, Lumbar Compression Fracture, Rheumatoid Arthritis, Coronary Artery Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death U 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 ID Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? 0 YES 0 N 21d. WERE AUTOPSY FiNOtNGS AVAILABL 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 it W i F Ft; r E uz 23a. DATE OF DEATH (Mo., Day, Yr.) July 12, 2015 z 124a. a CI' i E , Nat u w z 2 0 o f- g o DATE SIGNED (Mo.. Day, Yr.) 1 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 13, 2015 23c. TIME OF DEATH 11:04 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD O 23d. To the best of my knowledge, death occurred at the time, date and place .8 2 o and due to the cause(s) stated. (Signature nd Title) .8 g Jay C. Anderson, MD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the tim date and place and due to the tassels) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ® NO 0 PROBABLY 0 UNKNOWN ❑YES ®NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print .....Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 • REGISTRAR'S SIGNATURE 28b. DATE FILED BY REZ;1eRP R X11$ ; Day Yf.) July 21, 2015 128a. ailtd-4;e4C WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASeAVNIVIe MENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR41IT oe'; DATE OF ISSUANCE 07/24/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 201B0007 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY SCOOP."-. ASSISTANT STATE REGISTRAR DEPARTMENT ,bF MEAL7H' AND - HUMAN'SERYYGEE 15 04212