Laserfiche WebLink
To be completed by: CERTIFIER 1 1 To be completed /verified by: FUNERAL DIRECTOR <br />1 <br />1. DECEDENTS -NAME (First, Middle, Last, Suffix) <br />Cecil James Zornes Sr <br />2. SEX ' <br />Male' <br />'3 DATE tF DEATH (Ma., Day, Yr.) <br />October 18, 2015 <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Aurora, Nebraska <br />5a. AGE - Last Birthday <br />5b. UNDER 1 YEAR <br />5c. UNDER 1 DAY <br />6. DATE OF BIRTH_(Mo., Day, Yr.) <br />January 6, 1929 <br />(Yrs.) <br />86 <br />MOS. <br />DAYS <br />HOURS <br />MINS. <br />7. SOCIAL SECURITY NUMBER <br />506 -26 -1199 <br />8a. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility <br />❑ ER/Outpatient ❑ Decedent's Home <br />❑ DOA ❑ Other(Specify) <br />8b. FACILITY -NAME (if not Institution, give street and number) <br />Golden LivingCenter -Grand Island Lakeview <br />8c. CITY OR TOWN OF DEATH (Include Zip Code) <br />Grand Island 68801 <br />8d. COUNTY OF DEATH <br />Hall <br />9a. RESIDENCE -STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY OR TOWN <br />Grand Island <br />9d. STREET AND NUMBER <br />1405 West Hwy 34 <br />9e. APT. NO. <br />9f. ZIP CODE <br />68801 <br />9g. INSIDE CITY LIMITS <br />® YES ❑ NO <br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married <br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name <br />Eileen Frances Feddersen <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />Elza Zornes <br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) <br />Aida Thomas <br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. <br />(Yes, No, or Unk.) Yes 11/10/1948- 06/09/1952 <br />14a. INFORMANT -NAME <br />Eileen Frances Zornes <br />14b. RELATIONSHIP TO DECEDENT <br />Wife <br />15. METHOD OF DISPOSITION <br />® Burial ❑ Donation <br />❑ Cremation ❑Entombment <br />❑ Removal ❑ Other (Specify) <br />16a. EMBALMER - SIGNATURE <br />Katie M. Smydra <br />16b. LICENSE NO. <br />1454 <br />16c. DATE (Mo., Day, Yr.) <br />October 26, 2015 <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE <br />Westlawn Cemetery Grand Island Nebraska <br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) <br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska <br />17b. Zip Code <br />68801 <br />CAUSE OF DEATH (See instructions and examples) <br />18. PART 1. 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 <br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. <br />IMMEDIATE CAUSE: onset to death <br />IMMEDIATE CAUSE (Final a) Dementia Years <br />disease or condition resulting <br />in death) DUE TO, OR AS A CONSEQUENCE OF: i i onset to death <br />Sequentially list conditions, it b) 1 <br />1 <br />any, leading to the cause listed 1 <br />on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death <br />Enter the UNDERLYING CAUSE c) I <br />t <br />(disease or injury that initiated <br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death <br />LAST I <br />d) 1 <br />t <br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />❑ YES ID NO <br />20. IF FEMALE: <br />❑ Not pregnant 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 />t <br />❑ Unknown if pregnant within the past year <br />21a. MANNER OF DEATH <br />® Natural ❑ Homicide <br />❑ Accident ❑ Pending Investigation <br />❑ Suicide ❑ Could not be determined <br />21b. IF TRANSPORTATION INJURY <br />❑ Driver /Operator <br />❑ Passenger <br />❑ Pedestrian <br />❑ Other (Specify) <br />21c. WAS AN AUTOPSY PERFORMED? <br />❑ YES ® NO <br />21d. WERE AUTOPSY FINDINGS AVAILABLE <br />TO COMPLETE CAUSE OF DEATH? <br />❑ YES ❑ NO <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br />22b. TIME OF INJURY <br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) <br />22d. INJURY AT WORK? <br />❑ YES ❑ NO <br />22e. DESCRIBE HOW INJURY OCCURRED <br />221. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE <br />a W <br />3 F <br />Eti EI <br />23a. DATE OF DEATH (Mo., Day, Yr.) <br />October 18, 2015 <br />z w <br />.t s LI <br />i E Y <br />oa.eX o <br />w z <br />2 C O <br />~ u o <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24b. TIME OF DEATH <br />23b. DATE SIGNED (Mo., Day, Yr.) <br />October 19, 2015 <br />23c. TIME OF DEATH <br />10:25 PM <br />24c. PRONOUNCED DEAD (Mo., Day, Yr. <br />24d. TIME PRONOUNCED DEAD <br />0 < 0 23d. To the best of my knowledge, death occurred at the time, date and place <br />c- and due to the causa(s) stated. (Signature and Title) <br />2 Travis S. Hageman, MD <br />24e. On the basis of examination and /or investigation, in my opinion death occurred at <br />the time, date and place and due to the causes) stated. (Signature and Title) <br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN <br />26a. HAS ORGAN OR <br />❑ YES <br />TISSUE DONATION BEEN CONSIDERED? <br />El NO <br />26b. WAS CONSENT GRANTED? <br />Not Applicabte if 26a is NO ❑ YES ❑ NO <br />27. NAME, TITLE A D ADDRESS OF CERTIFIER (Type or Print <br />Travis S. Hageman, MD, 729 North Custer Avenue, <br />Grand Island, Nebraska, 68803 <br />REGISTRAR'S SIGNATURE % / <br />12 t <br />tr/`T�v <br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br />October 20, 2015 <br />I <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASJEA"DEPARTMENT OF HEALTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR.- VITALiRECORDS. <br />DATE OF ISSUANCE <br />10/23/2015 <br />STATE OF NEBRASKA <br />201507722 <br />STANLEY S. COOPER <br />ASSISTANT STATE REGISTRAP, <br />DEPARTMENT OF HEALTH ANQ <br />LINCOLN, NEBRASKA HUMAN SERVICES - <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN Sp <br />CERTIFICATE OF DEATH <br />15,06073 <br />