|
;Ivo Rltii. 4M elokaA, ' ,4111 t 335 .l§ 4 . 4 .
<br />STATE OF NEBRASKA
<br />iiW
<br />fier
<br />$ _ _ _Intaii*Ziirghnitt44,
<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 HEA4TH . HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />- ,
<br />DATE OF ISSUANCE
<br />12/2/2016
<br />LINCOLN, NEBRASKA
<br />STANLEY S. VOOPER
<br />20170015 A E T N S T TA H T E E AL R T E H G A IS N T D RAR
<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 />Andrew Branch Markham
<br />4..CITY AND STATE OR 'TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cortland, New York
<br />7. SOCIAL SECURITY NUMBER
<br />506-36-1720
<br />8b. FACILITY (It not Institution, give street and number)
<br />1308 West 4th Street
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a: RESIDENCE-STATE.
<br />Nebraska.
<br />9b. COUNTY
<br />Hall
<br />O. PART I. Enter the chain of events- -diseases, injuries, or complications-that directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause On it line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />r APPROXIMATE.INTERVAE
<br />onset to death
<br />Minutes
<br />9d. STREET AND NUMBER
<br />>, 1308 West 4th Street
<br />100. MARITAL STATUS. AT TIME OF DEATH IR] Married 0 Never Married
<br />0 Married, butseparated 0 Widowed 0 Divorced 0 Unknown
<br />0.
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />8 (Yes, No, or link) No
<br />2 15. METHOD OF DISPOSITION
<br />,2 0 Bud& 0 Donation
<br />Not Embalmed
<br />0 Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER-SIGNATURE
<br />5a, AGE Last Birthday
<br />(Yrs.)
<br />83
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />Leon Markham
<br />12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Beatrice McKinney
<br />14a. INFORMANT-NAME
<br />Suzanne Marie Markham
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, state)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />onset to death
<br />Minutes
<br />death) . DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequontiany hat eitelditiOne, if ,b) cardiac Arrest
<br />an a
<br />yleading. the cause
<br />o
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />••(lise354,0"PfurY0!fit initiated
<br />the events Mending:In death/ DUE TO OR AS A CONSEQUENCE OF
<br />LAST •.:. d
<br />onset to death
<br />onset
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS contributing to the death but not resulting in the underlying cause given In PART I.
<br />Chronic Obstructive Pulmonary Disease And Heart Disease
<br />20. IFiEEMAI:E::
<br />• 0 Not pregnant Within pact year
<br />0 Pregnant at time of death
<br />Not pregnant, but pregnant within 42 days of death
<br />• • El Not pre$01arklitit pregnant 43 days to 1 year before death
<br />wj allpl If mon' within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 0
<br />U
<br />E o.:
<br />' DYES O>o
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />28. DID TONACCO USE TO THE DEATH?
<br />0 TES 0 NO •• o PROBABLY E UNKNOWN
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Suzanne Marie Coatman
<br />21a. MANNER OF DEATH
<br />235. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<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 />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />DAYS
<br />9e. APT. NO.
<br />16b. LICENSE NO.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES ENO
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC
<br />0 ER/Outpatient E Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />0 Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />CITY / TOWN
<br />9f. ZIP CODE
<br />68801
<br />21b, IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />STATE
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 21, 2016
<br />6. DATE OF BIRTH (Mo., Day, Yr,
<br />July 29, 1933
<br />9g. INSIDE cm( LIMITS
<br />[5] YES 0 NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />November 23, 2016
<br />STATE
<br />Nebraska
<br />17b Zip Code
<br />68801
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES [3 NO
<br />21c. WAS AN AUTOPSypERFONMED:?:;::
<br />DYES 0 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />YES 0 NO
<br />ZIP cope
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />November 23, 2016 Approx. 01:00 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEM)
<br />November 21, 2016 08:00 PM
<br />24e. On the basis of examination and/or investiga ion, in my opinion death Occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tide)
<br />Mean Alexander, Hall Deputy County Attorney
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 yEs
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Megan Alexander, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE d _
<br />28b. DATE FILED BY REGISTRAR(Mo„ Day, Yr.)
<br />November 28, 2016
<br />
|