|
RGH
<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 />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />DATE OF ISSUANCE STANLEY S. COOPER
<br />n ASSISTANT STATE REGISTRAR
<br />11/8/2016 2 016 0 8 3 9 9 HUMAN SERVICES DEPARTMENT HEALTH AND
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Merle Joseph McCoun
<br />4. : CITY AND STAIE:OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Royal, Nebraska .:
<br />7. SOCIAL SECURITY NUMBER
<br />508 -38 -1124
<br />8b: FACILITYNAME (If :not 'Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zlp Code)
<br />Grand Island 68803
<br />9a. RESIDENCE-STATE :` .:
<br />Nebraska'
<br />9d. STREET AND NUMBER
<br />201 East 13th Street
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married 0 Widowed Divorced ❑ Unknown
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes,` No, 'or Unk.) No,
<br />15. METHQD':OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />in death)
<br />Sequentially gst erinflrtioitik If
<br />>eny, ieadingito:thf cBuseMista* .
<br />on lines
<br />20. IF
<br />Not Pregnant .Wthin past year
<br />❑ Pregnant at time of death
<br />.:. 0 Not pregnant, but pregnant within 42 days of death
<br />141 pregnant, Did presltaot 4 3 days to 1 year before death
<br />Unknown if pregnant withinllis past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK
<br />YES. .D: NO .:::::.:::
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ®NO ❑ PROBABLY ❑ UNKNOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 28: `2016
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 31, 2016
<br />9b. COUNTY'
<br />Hall
<br />16a. EMBALMER-SIGNATURE Tracey Dietz
<br />22b. TIME OF INJURY
<br />23c. TIME OF DEATH
<br />03:21 AM
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />81
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />O' Suicide ❑ Could not be determined
<br />23d. 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 />John A, Wanoner, MD
<br />5b. UNDER 1 YEAR
<br />• MOS.:
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />9e. APT. NO.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES .. e
<br />MINS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient
<br />❑ ER/Outp
<br />O DOA
<br />OTHER ❑ Nursing Home/LTC m
<br />❑ Decedent's Hoe
<br />❑ Other (Specify)
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River.;
<br />21b. IF TRANSPORTATION INJURY
<br />❑ . Driver /Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />9f. ZIP CODE
<br />68883
<br />14a. INFORMANT -NAME
<br />Gloria. McCoun
<br />16b. LICENSE NO.
<br />1328.
<br />17a. FUNERAL HONf NAM£ AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Horne. 1123 W. 2nd. Grand Island, Nebraska
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Qiabetes.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 28, 2016
<br />6. DATE OF BIRTH (Mo., Day, Yr,)
<br />September 5, 1935
<br />9g. INSIDE CITY:
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, . Middle, Last, Suffix) If wife, give maiden name
<br />Gloria Boltz
<br />11. FATHER'S- NAME (First, Middle, Last, Suffix)
<br />Bernard Elroy McCoun
<br />12. MOTHER'S -NAME (First, Middle,
<br />Winifred Willats
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo.,: Day :Yr.)
<br />November 4, 2016
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />CITY /TOWN
<br />Grand Island
<br />STATE
<br />Nebraska'
<br />17b.;Ztp Code: :..:
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1 • t.?ART'1.Ee1sr the tltain:ot events- -diseases, injuries, or complications -that directly caused the death. DONOTenteetenninal events such as cardiac arrest,
<br />respirataty kneel; Or 0eritr,eurar fibrillation without showing the etiology. DO NOT ABBREVIATE: Enter only one cause on 4 lint. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Congestive Heart Failure
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />onset to death::
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Coronary Artery Disease
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />..tdNase•tu that Initialed,
<br />onset to death
<br />;tps everts resenrng i de
<br />d)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death:•
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NS
<br />21c. WAS AN AUTOPSY:VERFORMED ?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF: DEATH?
<br />❑YES ❑ NO... : .: .
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc: (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE IM i';::�ZiP CEDE
<br />24b. TE OF DEATH
<br />24d. TIME PRONOUNCEQ DEAD
<br />24e. On the basis of examination and/or investigation, M my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tide)
<br />26b. WAS CONSENT GRANTED? ❑
<br />Not Applicable if 26a is NO Y 0 No
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />John A. Wagoner, MD, 800 N Alpha Street, Grand Island, Nebraska, 6880
<br />26a. REG SIGNATURE
<br />28b. DATE FILED BY REGISTRAR(Mo., D'ay, Yr.)
<br />November 1, 2016
<br />avei
<br />16:08541
<br />
|