201601367 - Laserfiche WebLink

Browse

1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Laura Jacqueline Sorensen 2. SEX female - ° - 3. DATE OF DEATH (Mo., Day, Yr.) 1 - O 1 - , 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 81 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) October 26, 1929 MOS. DAYS HOURS MINE. 7. SOCIAL SECURITY NUMBER 508 -32 -8335 _ 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ®Nursing Home /LTC ❑Hospice Facility ❑ ER/Outpatient ❑Decedent's Home ❑ DOA ❑Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society-Grand Island Village 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 124 West 17th 9e. APT. NO. 9f. ZIP CODE 68801 99, INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Jack Sorensen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Joseph Jess Kellogg 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Laura Florence 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk) No 14a. INFORMANT -NAME Jack Sorensen 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) March 18, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park 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 CAUSE OF` DEATH (See instructions and examples) 1e. 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 onset to death >24 Hours 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) Respiratory Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Subdural Hematoma Unknown If Traumatic Or Non - traumatic > 1 Month any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Alzheimers Dementia >3 Years (disease or injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: 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. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF 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 ® 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 El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE 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 . I Y g z � u 0 o f 23a. DATE OF DEATH (Mo., Day, Yr.) March 12, 2011 e 8 `a 0 1 g u)< z $ w 0 B 4 0 s 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 23b. DATE SIGNED (Mo., Day, Yr.) March 17, 2011 23c. TIME OF DEATH 05:00 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jennifer L. Brown, MD Zoe, On the basis of examination and/or fnvesfigatlon, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, IHYSICIAN Jennifer L. Brown, MD, 729 North Custer Avenue, I 26a. HAS ORGAN OR I ❑ YES ASSISTANT Grand Island, Nebraska, ISSUE DONATION BEEN CONSIDERED? /3 NO CORONE PHYSICIAN OR COUNTYY A 68803 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO ORNEY) (Type or Print) 1 28a REGISTRAR'S SIGNATURE I <JVO� 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) I March 17, 2011 STATE OF NEBRASKA 201.601367 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT QF HEALTH .AND HUMAN ' SiE4WICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR/ 9KA PARTMEfl,T OF:HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR:V/I i,$L.RFC�DRDS( ti DATE OF ISSUANCE S1;4NLEY y CfI�QP R. �Qa5,T ,�7;A� HIE TRAR DEpAYi 1MENT OF HEALJ`h AND , LINCOLN, NEBRASKA HUML gip/ICES t . STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICESz, - -- -- ,.- _ CERTIFICATE OF DEATH 03/24/2011 11 00890