201608107 - Laserfiche WebLink

Browse

To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Hazel Jane Lacy 2. S t " S ',. • ^ Fenta(e r ; , S� l9,TE'O�4FAN (Mo., Day, Yr.) , Aueia t 2$72014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cairo, Cairo, Nebraska 5a. AGE - Last Birthday MO 89 5b. UNDER 1 YEAR 5c. UNDER 1tDAY " ' 6. bA I E OVBIRTH (Mo., Day, Yr.) April 5, 1925 I DAYS HOURS I MINS. 7. SOCIAL SECURITY NUMBER 506 -20 -5341 8b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN I Grand Island 9d. STREET AND NUMBER 19e. 1824 N. Kruse APT. NO. I 8f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 105. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ® WIdowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Melvin Wray Lacy 11. FATHER'S -NAME (First, Middle, Last, Suffix) Emil Luhn 12. MOTHER'S -NAME (First, Middle, Malden Surname) Hazel Gertrude Orndoff 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Marti Lacy 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Patricia R. Curran 16b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) September 2, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1$. PART I. Enter the chain of events - -diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, r APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest, Progressive Osteoporosis disease or condition resulting onset to death Years in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, If b)Aging, Chronic Steroid Use I Years any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) I 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I. Polymyalgia Rheumatica,Hypertension, Chronic Pain Syndrome, History TIA /Stroke, History Pulmonary Embolism 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? DYES El NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before Math ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑Acc ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 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 building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 8 W F a u z 23a. DATE OF DEATH (Mo., Day, Yr.) August 28, 2014 b' E I 1 n c z Z 8 ~ § o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 2, 2014 23c. TIME OF DEATH I 09:05 PM 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3 d. To the best of my knowledge, death occurred at the time date and place g C and due to the cause(s) anted. (Signature and Title) r- f Jane A. McDonald, MD occurred 2. 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE .O • ATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN DYES 0 NO 26b. WAS CONSENT GRANTED? Not Applicable H 28a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) September 2, 2014 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 D TMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI.VI R5COR 8;, DATE OF ISSUANCE 09/03/201 LINCOLN, NEB RASKA STATE OF NEBRASKA 201 08107 4 "ST,ANtEft. COOPFz '•. ASSISTANT SFA-TE REGISir FKA . DLRT�F �HL�7L STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEgMICES . e CERTIFICATE OF DEATH f, `; •• '' 14 04354