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01A
<br />STATE OF NEBRASKA
<br />iiiatay
<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 />DATE OF ISSUANCE
<br />9/23/2016
<br />LINCOLN, NEBRASKA
<br />STANLEY S. COOPER
<br />201607336 DEPARTME HEA A ND AR
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH' AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Joyce Nadine Engel
<br />4.
<br />AND : STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Doniphan, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506 -28 -3409
<br />b. FACILITY-NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 68803
<br />k RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />3510 W. Lepin Road
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />John Stonehocker
<br />13. EVER IN U.S. ARMgD FORCES? Give dates of service if Yes.
<br />(Yee; No, or unit.) No
<br />15. MEtHOD OF DISP 16a. EMBALMER-SIGNATURE
<br />Burial 0 Donation Tracey Dietz
<br />❑ Cremation 0 Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />0 Removal 'Q Other(Specify)
<br />Doniphan
<br />7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Funeral Home. 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PARTt. Enter the 'Shainofevents- -diseases, injuries, or complications -that directly caused the death. 00 NOT enter temdnal events such as cardiac arrest,
<br />respiratory arrest, or Ventrkular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final al Acute Cerebral Vascular Accident
<br />disease or condition resulting
<br />in:. death)
<br />S Seco/1104) Nkt coral
<br />any, 7ead,rtg to the cause
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease y' injury filet Initiated,
<br />the ehadts retuning 1d death)
<br />LAST
<br />0. IF'FEMALE: 's
<br />❑ Notpregnamtipithinpastyear
<br />0 Pregnant at time of death
<br />❑ Notpregnant,. pregnant within 42 days of death
<br />❑ Not pregnant but pregnald days to 1 year before death
<br />❑ uitknowntfpregnant Withir+ the past year
<br />22a. DATE OF INJURY (M0:, Day, Yr.)
<br />20. iNJURY
<br />DYES ❑NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23a. DATE OF :DEATH (Mo., Day, Yr.)
<br />March 9, 2011
<br />230, DATE SIGNED (Mo., Day, Yr.)
<br />M 17 2011
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />83
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC
<br />Ea ER/Outpatient ❑ Decedent's Home
<br />0 DOA ❑ Other (Specify)
<br />❑ Hospice Facility
<br />9c, CITY OR TOWN
<br />Doniphan
<br />3Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name:,
<br />Louis Engel
<br />14a. INFORMANT -NAME
<br />Louis Engel
<br />Cedarview Cemetery
<br />STATE
<br />Nebraska'•
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />-/Hypertension
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />22b. TIME OF INJURY
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23c. TIME OF DEATH
<br />08:33 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Kenneth Vetiel, MD
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />CITY /TOWN
<br />25. DID TOBACCO- USE CONTRIBUTE TO THE DEATH?
<br />0 YES J NO Q PROBABLY ❑ UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kenneth Vetted, MD, 2116 W Faidley #400, Box 9802, Grand Islan
<br />28a, REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 0 NO
<br />Sb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />5c. UNDER 1 DAY
<br />2. SEX
<br />Female
<br />HOURS
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mildred Hockenberry
<br />16b. LICENSE NO.
<br />1328
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />other: (SpecifYI
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />ka, 68803
<br />MINS.
<br />9f. ZIP CODE
<br />68832
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 9, 2011
<br />6. DATE OF BIRTH (M
<br />July 17, 1927
<br />D a y , Yr.)
<br />9g. INSIDE CITY LIMITS
<br />❑ YES Ea NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (Mo., Day, Yr.)
<br />March 12, 2011
<br />17b, zip Code
<br />68801
<br />A PPROXIMATE:INTERVAL.
<br />onset to death
<br />Hours
<br />onset to doatt
<br />Decades
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES El NO
<br />21c. WAS AN AUTOPSY PERFO
<br />❑ YES ® NO
<br />ED?
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH ?
<br />❑YES 0 N
<br />STATE 21P CODE
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<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 ❑ YES
<br />28b. DATE FILED BY REGISTRAR(Mo„ Day,Yr.) •
<br />March 17, 2011
<br />
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