201602092 - Laserfiche WebLink

Browse

STATE OF NEBRASKA , WHEN ! nits +' " COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 201602092 03/01/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH '' STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES w U. F W U Ll. a• E 0 u m .0 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Dormond Eugene Metcalf 4, CITY AND STATE OR TE RRITORY, OR FOREIGN COUNTRY OF BIRTH Bu rwef, Neb raska 7. SOCIAL SECURITY NUMBER 508-48-2002 8b. FACILITY -NAME (If not Institution, give street and number) 7900 N, Huey 281 8c, CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE -: Nebraska 9d. STREET AND NUMBER 7900 N. Hwy 281 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married © Married, but separated`, ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Earl Metcalf 1.3. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes " 05/20/1952- 05/19/1960 15. METHOD OF DISPOSITION El Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ] Other (Specify) 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE William D. Greenway 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Broken Bow Cemetery Broken Bow STATE ebrasl€a 17a. >FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Jacobsen- Greenway Funeral Home, 411 0 Street, PO Box 112, St. Paul, Nebraska IMMEDIATE CAUSE (Final a) Metastatic Lung Cancer disease or condition resulting 171 death) CAUSE OF DEATH (See instructions and examples) 9, PART I. Enter the chain Of events -- diseases, injuries, or complications -that directly caused the death, PO NOT enter terminal gt gnts such as cardiac arrest, respiratory arrest, or yentricii)ar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: APPROXIMATE 1 NTERVAL onset to death 1 Year DUE TO, OR AS A CONSEQUENCE OF: b) Sequentiallylist conditions, if any, leadingl0 theausa listed; on line a. - -- DUE TO, OR AS A CONSEQUENCE OF: c) onset to death Enter the UNDERLYING CAUSE ..(disease er injury that initiated:.: the events res death) LAST: biting DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. IF FEMALE: ❑ NotpregnaM within past year ❑. pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnantYbut p 43 days to 1 year before death ❑ Unknown if pregnant Within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ] YE5 1 NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE "ZIP CODE 23a. DATE OF DEATH (Mo„ Day, Yr.) Fearuary 21,:2016 23b. DATE SIGNED (Mo., Day, Yr.) February 22, 2016 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Cauld' not be determined 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 06:30 PM Z3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Richard Freehling, MD 5a, AGE - Last; (Yrs.) 84 hday 1 8a. .. REGI$TRAFr5 SIGNATURE �- / /7� 5b. UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL 0 Inpatient U E RIO ufpatlent ❑ DOA OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand, Island 9e. APT. NO. 10b. NAME OF SPOUSE (First; Bonnie J Powell Middle, Last, Suffix) If wife, give maiden n e 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Geneva Miller 14a. INFORMANT -NAME Bonnie J Metcalf 8d. COUNTY OF DEATH Hall 16b. LICENSE NO. 0913 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 245. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 25. DID TOBACCO:USE CGNTRIBUTE TO THE DEATH? ® YES ❑ NO 0 PROBABLY ❑ UNKNOWN 26a BEEN ^ CONSIDERED? . HAS ORGAN' OR TISSUE ++ A110N ❑ YES gl NO 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) February 21, 2016 July 16, 1931 6. DATE OF BIRTH (Mo Day, W4 9g. INSIDE CITY LIMITS ❑ YES El NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) February 24, 2016 17b, Zip Code 68873 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? .: ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH / :. ❑YES NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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) 26b. WAS CONSENT GRANTED? ?' Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Frueh(ing,MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Mo., February 26, 2016 Day Yr)