201700266 - Laserfiche WebLink

Browse

STATE OF NEBRASKA IAA• � =bp IY " a ;429! C owe W .0. E 0 0 1. 1-- 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Cecil Santa Stoner 4. CITY!AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Aurora, Kansas 7. SOCIAL SECURITY NUMBER 534.24 -3606 8tf. FACILITY -NAME (If not Institution, give street and number) O I- CHI Health St. Francis ✓ 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE • Nebraska ▪ 9d. STREET AND NUMBER • 2908 West 16th Street 10z■ MARITAL STATUS AT TIME OF DEATH ®Married ❑ Never Married ❑ Married, but separated .0 Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Clifton S Stoner 3, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 02/17/1944-04/10/1946 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment 0 Removal ❑ Other(Specify) 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State);r Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska in death) DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) (dlseai a or injury that initiated Me events resulting in death) LAST:; 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant; bb pre gnant within 42 days of death 0 not pregnant, pre gnant 43 days to 1 year before death ❑ unknown if pregnant wtt In the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT 1NO ?" ❑ YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 1`2 Z 0 2 U o WHEN THIS " 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 11/21/2016 LINCOLN, NEBRASKA 23a DATE OF DEATH (Mo., Day, Yr.) November '91, 2016 23b. DATE s)GNE• (Mo., Day, Yr.) 23c. TIME OF DEATH November 14, 2016 12:07 AM 20170024 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Tracey Dietz Westlawn Cemetery DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) ane'A. McDonald, MD 5a. AGE - Last Birthday (Yrs.) 92 14a. INFORMANT - NAME Betty J Stoner 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ . Accident ❑ Pending Investigation Suicide ❑ Could riot be determined CITY /TOWN 25. DID TOBA000 USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803, b UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL 181 Inpatient ❑ ER/Outpatient ❑ DOA STANLEY S.°COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male HOURS 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9e. APT. NO. 19f. ZIP CODE 68803 12. MOTHER'S -NAME (First, Middle, Elsie Bates 16b. LICENSE NO. 1328 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island CAUSE OF DEATH (See instructions and examples) 5c. UNDER 1 DAY MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 1. Enter the in of events diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ipiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) End -stage Coronary Artery Disease, Systolic Heart Failure disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: eguenuatIy listcdndttions, if 23) Diabetes Mellitus, Hypertension, Chronic Kidney: Disease Stage Ill, Chronic Atrial Fibrillation any, leading cause tisrp3` on line a. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger Q Pedestrian 0 Other(Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) C U yy^^ A f �,U 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES Ej NO 3. DATE OF DEATH (Mo., Day, Yr.) November 11, 2016 6. DATE OF BIRTH lMo., Day, Yr) December 17, 1923 lab. NAME OF SPOUSE. (First, ,Middle, Last, Suffix) If wife, give maiden name Betty J Grubbs Maiden Surname) �] Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) November 18, 2016 17b,ZIPCode '. 68801 • APPROXIMATE INTERVi Years onset to death Years onset to death STATE Nebraska onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES gI NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH' : ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED D 24e. On the basis of examination and /or investigation, in my opinion death occurred 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 ONES 28b. DATE FILED BY REGISTRAR (Ma., Day, Yr.) November 15, 2016 iD © Ni