201601478 - Laserfiche WebLink

Browse

To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Enos Carl Peterson 2. SEX ' ..' j f `• Male - 3,DATEOF DEATH (Mo., Day, Yr.) April 1,6 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs) 78 5b. UNDER 1 YEAR 5c. UNDER -1 DAY t. DATE OF BIRTH (Mo., Day, Yr.) October 12, 1935 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -38 -5246 8b. FACILITY -NAME (If not Institution, give street and number) 1640 E. Airport Rd 8a. PLACE OF DEATH HOSPITAL 0 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 68801 8d. COUNTY OF DEATH Hail 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 1640 E. Airport Rd r e. STREET AND NUMBER l e. APT. NO. 9f. ZIP CODE 68801 8g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 100. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name Sandra Fae Becker 11. FATHER'S -NAME (First, Middle, Last, Suffix) Chris Peterson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Zelma Nelsen 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or unk.) Yes 11/10/1952- 10/11/1956 14a. INFORMANT -NAME Sandra Fae Peterson 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Katie M. Ewald 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) April 19, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 r CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 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 onset to death Immediate 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 Iist conditions, if b) Chronic Obstructive Pulmonary Disease (COPD) 3-4 Years any, leading to the cause listed on Ilse a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (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 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of me o death P ❑ 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 ❑ Pen Investigation ❑ suicide ❑ Could determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 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 buliding, 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 w v u. } u i 23a. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) April 17, 2014 24b. TIME OF DEATH Approx. 04:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) I 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) April 16, 2014 24d. TIME PRONOUNCED DEAD 08:04 AM 8 O 3d. To the best of my knowledge, death occurred at the time, date and place a and due to the cause(s) stated. (Signature and Title) ` f 24e. On the basis of examination and/or Investigation. in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jon Hendricks, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES El NO 260. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jon Hendricks, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 I 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 22, 2014 STATE OF NEBRASKA 201601478 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 NEBRASKA.WARTMENT OF HTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO - VI`1r, `L RE O AS c, `, 't L`11 ,��s QQ STANLEY'S CO /� U 't V V O Q AR,TMENT OFEEA LTAND LINCOLN, NEBRASKA :7-1tiMAN'SEtVi't.zE ' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERy10ES DATE OF ISSUANCE 04/28/2014 CERTIFICATE OF DEATH ;� ' : ° ,: