201607185 - Laserfiche WebLink

Browse

STATE OF NEBRASKA WHEN THIS I` 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 9/30/2016 LINCOLN, NEBRASKA 201607185 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH avti STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Judy Ann Engel 4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hastings, Nebrask 7. SOCIAL SECURITY NUMBER 505-52 -6750 8b. FACILITY-NAME (If not Institution, give street and number) CHI Health St. Fra ncls 9a REStDENCE•STATE Nebraska 13;: EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) NO 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Pulmonary Embolus disease or condition resulting in!dea£hl Sequentially List send tiafre, if any, leading td the,CabsB bated on lines 20. IF FEMALE. ® Not pregnant within past year ❑ Pregnant at time of death ❑ NatprmgnantiAut pregnant within 42 days of death ❑ Not pregnant, but prsgnent 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJ URY AT INOR#f.7 OYES ❑NO 25. IDID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES Ea NO ❑ PROBABLY ❑ UNKNOWN 28a REGISTRAR StONATURE 5a. AGE Last Birthday (Yrs.) 74 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, butseparated ❑ Widowed ❑ Divorced ❑ Unknown 17a. FUNERAL HOME NAM € AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island; Nebraska 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23a. DATE OF DEATH (Mo., Day, Yr.) September:22, 2016 23b. DATE SIGNED (Mo., Day, Yr.) September 23, 2016 23c. TIME OF DEATH 06:25 AM a O 3d. To the best of my knowledge, death occurred at the time, date and place G and due to the cause(s) stated. (Signature and Title) ' Larry, L. Hansen, MD 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Larry L. Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, 68803 - bb. UNDER 1 YEAR MOS. DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand; Island 68803 9d. STREET AND NUMBER 528 Wyandotte 16a. EMBALMER-SIGNATURE Katie M. Smvdra 2. SEX Female 5c. UNDER 1 DAY HOURS 9e. APT. NO. 14a. INFORMANT- NAME Vernon Elmer Engel 16b. LICENSE NO. 1454 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 121 NO MINS. 9f. ZIP CODE 68801 3. DATE OF DEATH (Mo., Day, Yr.) September 22, 2016 July 31, 1942 6. DATE OF BIRTH (MO,, .Day Yr4 8a. PLACE OF DEATH HOSPITAL kl Inpatient 0 ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island' 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Vernon Elmer Engel 11. FATHER'S -NAME (First, Middle, Last, Suffix) Louis Helzer 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Bertha Williams 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day, Yr.) September 26, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY / TOWN Grand Island STATE Nebraska 17b, Zip Coda 68801 CAUSE OF DEATH (See instructions and examples) 14. PART I. Enter the chain of events -- diseases, injuries, or complications -that directly caused the death. 00 NOT enter temlinal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line.'. Add additional lines if necessary. A P P ROXIM ATE1 N TERVA L:. onset to death 3 Days DUE TO, OR AS A CONSEQUENCE OF: b) Malignant Melanoma Metastatic To Brain And Lungs onset to death 3 Years Enter the UNDERLYING CAUSE / disease or (njury that init+aterl the events resulting m 0041 0) i:.. ...' DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSEOF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 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 :1140 28b. DATE FILED BY REGISTRAR (Mo., bay, Yr.) September 26, 2016