|
To be completedNerified by: FUNERAL DIRECTOR
<br />-
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suff)x)
<br />Thomas Shane Jordan
<br />2. SEX r ,
<br />Male •
<br />3. DATE'OF DEATH (Mo., Day, Yr.)
<br />September 8, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />70
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY .
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />-
<br />February 16, 1945
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />505-54-4744
<br />8b. FACILITY-NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL I@ Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<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 />408 West 13th St.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />rA YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Kathleen Cargill
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />Bernard Jordan
<br />12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Dorothy Ganow
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT-NAME
<br />Kathleen Jordan
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />gl Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER-SIGNATURE
<br />Chris McCoy
<br />16b. LICENSE NO.
<br />1191
<br />16c. DATE (Mo., Day, Yr.)
<br />September 11, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ..
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER I
<br />13. PART I. Enter the chain of events-diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2 Hours
<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:
<br />IMMEDIATE CAUSE (Final a)Hypoglycemic Coma
<br />disease or condition resulting
<br />in death)
<br />CUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Sequentially list conditions, if b) Diabetes Mellitus 1 Chronic
<br />any, leading to the cause listed I
<br />I
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Enter the UNDERLYING CAUSE c )
<br />I
<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
<br />d) 1
<br />1
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Peripheral Vascular Disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES 0 NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />D Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown 4 pregnant within the past year
<br />21a. MANNER OF C
<br />0 Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES IZ NO
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 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 />D YES 0 NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />I 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 8, 2015
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />1 1.1 23b. DATE SIGNED (Mo., Day, Yr.)
<br />Ti• tf, f; September 11, 2015
<br />1 3
<br />23c. TIME OF DEATH
<br />11:28 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />If
<br />0 < ("' 29d. To the best of my knowledge, death occurred at the time, date and place
<br />z 2 and due to the cause(s) stated. (Signature and Title)
<br />I '3 Ryan D. Crouch, DO
<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 cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES IR NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR
<br />0 YES
<br />ISSUE DO ATION BEEN CONSIDERED?
<br />EC NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable ff 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIEIT(Type or Pnnt
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand
<br />,
<br />Island, Nebraska, 68803
<br />1 28a. REGISTRAR'S SIGNATURE A
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 14, 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 NEBRA404 DEPAPTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR"VIT44 R
<br />DATE OF ISSUANCE
<br />09/18/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />2M08218
<br />StANLEY S...CODPiR
<br />SSISTANTATEREGISTRAR
<br />DEPARNENT IlEALTH AND
<br />tgiitt44 sErRtacs'
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />15 05272
<br />
|