|
iVawilkatAft0 ktekaalak doso
<br />NT:ii4gWITTNe
<br />teriirderf
<br />MRCWX"..AltiWBOtte),eMd
<br />taiskee--
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />• CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />• RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DAM OF ISSUANCE 201601732
<br />02/17/2016
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix)
<br />Eileen Delores Basnett
<br />4. CITY Afil) STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St
<br />7. SOCIAL SECURITY NUMBER
<br />507-70-0155
<br />fib. FACILITY-NAME If notinstitution, give street and number)
<br />F2 Ravenna Good Samaritan Center
<br />i • 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />E.1 Ravenna 50809
<br />• 9d. STREET AND NUMBER
<br />u .
<br />411 West Genoa Street
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />10a. MARITAL STATUS AT TIME OF DEATH D Married 0 Never Married
<br />0 Married, but separated E Widowed 0 Divorced
<br />11. FATHER'S-NAM (First, Middle, Last, Suffix)
<br />Henry Muhlbach
<br />g- 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT-NAME
<br />3 (Yes, No,orLlnlk.}NO Dennis Basnett
<br />11 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE
<br />O 0 Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />0 Removal 0 Other (Specify)
<br />Sodtown Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Rasmussen Mortuary, 311 Grand Avenue, Ravenna, Nebraska
<br />IS. PART I. Ester the chain of *Vents-diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal Events such as cardiac arrest,
<br />respiratory arrest, or ventricuiar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional 11000 41 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) End Stage Vascular Dementia
<br />disease or condition resulting
<br />in death)
<br />Sequentially list conaltkeris, if
<br />any, (eadinat° the clue! listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />idisease or injury that initiated
<br />the events resultina in death)
<br />LAST
<br />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
<br />OR CORONER CONTACTED?
<br />OYES 0 NO
<br />Hypertension, Hyperlipidemia, ChrOniC Arterial Fibrillation
<br />20. IF FEMALE 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY
<br />0 Not within past year 0 Natural 0 Homicide 0 Driver/Operator
<br />0 pre
<br />0 Net pregnant, at time of death 0 Accident Investigation 0 P assen g er
<br />gnant, but pregnant within 42 days of death
<br />0 Suicide 0 Could not be determined
<br />D Pending
<br />0 Pedestrian
<br />0 Not pra: it /2 nant,.1:t 43 days to 1 year before death 0 Other (Specify)
<br />0 Unkno past year
<br />22a. DATE OF INJURY (Mo., th
<br />., Day, Yr.) I22b. TIME OF INJURY I 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d, INJURY AT WORK7 i 22e. DESCRIBE HOW INJURY OCCURRED
<br />D YES 0 NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />2' 5 January 20, 2016
<br />5 23b. DATE SIGNED (Mo., Day, Yr.)
<br />cc aiL
<br />3 o
<br />2 (.2
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />9b. COUNTY
<br />Buffalo
<br />Tracey Dietz
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Cerebrovascular Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />5a, AGE - Last Birthday - Sb. UNDER 1 YEAR
<br />Unknown Marvin James Basnett
<br />12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Laura Meyer
<br />CAUSE OF DEATH ($ee i nstructions and examples)
<br />CITY/TOWN
<br />(Yrs.)
<br />94
<br />104. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />8a. PLACE OF DEATH
<br />HOSPITAL fl Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />23c. TIME OF DEATH
<br />January 27, 2016 07:30 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place ▪ ge z
<br />and due to the cause(s) stated. (Signature and Title) S z g
<br />28a. REGISTRAR'S SIGNATURE jej
<br />MOS. DAYS
<br />9c. CITY OR TOWN
<br />Ravenna
<br />jElciabit 44r
<br />1328
<br />STANLEY S. •OPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />9e. APT. NO.
<br />1 b. LICENSE NO.
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />El Other (Specify)
<br />8d. COUNTY OF DEATH
<br />B.'Jffa!C
<br />CaY/TOWN
<br />9f. ZIP CODE
<br />68869
<br />Buffalo County
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />g
<br />Steven Husen, MD o
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 265. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />D YES 0 NO Er PROBABLY 0 UNKNOWN 0 YES ID NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />• Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />A Cive
<br />MINS.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />16 00636
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 20, 2016
<br />6. DATE OF BIRTH (Mo„ Day, Yr,)
<br />September 21, 1921 •
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />0 YES 0 NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo., Day, Yr.)
<br />January 25, 2016
<br />STATE
<br />•Nebraska
<br />I 17b. Zip Code
<br />68869
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />>2 Years
<br />onset t:aerfa1
<br />>10 Years
<br />onset to death
<br />onset to death
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYES El NO
<br />21d. WERE AUTOPSY FINDINGS AvAiLABL
<br />TO COMPLETE CAUSE OP DEATH?,
<br />DYES 0 'NO
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED AD
<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 />26b. WAS CONSENT GRANTED? •
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 9, 2016
<br />
|