201700583 - Laserfiche WebLink

Browse

Pk ft 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 1/11/2017 LINCOLN, NEBRASKA 201.700583 STANLEY S. COOPER ASSIS ANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ta of . PART I. Enter the Chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enterlterminal events such as cardiac arrest, respiratory arrest, Or ventrltular 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) Congestive Heart Failure D isea se or condition resulting APPROX(MATEINTERVAL onset to death Years 1. DECEDENTS -NAME' (First, Middle, Last, Suffix) Harry Edwin Gregersen 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Neosho Falls, Kansas 7. SOCIAL SECURITY NUMBER 296 -22 -4031 8b. FACHITY•NAME (If not Institution, give street and number) O F Veterans Affairs Medical Center L.. 8c. CITY OR TOWN. OF DEATH (Include Zip Code) o Grand Island 68803 Zk 9a. RESIDENCE -STATE ft • Nebraska Ed. STREET AND NUMBER' >, 419 Johnson Dr v 1Oa. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑Married, but separated ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) C larence Peter Greqersen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Nadine Lovina Hayes E E 13. EVER IN U.S.. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes ;:08/16/1946- 03/10/1948 0 15. METHOD OF DISPOSITION Et Burial ❑ Donation 11 Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) Enter the UNDERLYING CAUSE (disease or, injury that initiated the events resustag m dea LAST .. • 20. IF FEMALE: ❑ Not pregnant within past year • ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ro Not pregnan tut ptagnast43 days to 1 year before death +�+ 0 if pregnant within the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 a 22d. INJURY AT:WORK? I I'''l ID YES ONO 5a. AGE - Last Birthday (Yrs.) 88 9b. COUNTY Hall MOS. 9c. CITY OR TOWN Grand Island 14a. INFORMANT -NAME Bruce Alan Greqersen 16a. EMBALMER - SIGNATURE Not Embalmed DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED Sb. UNDER 1 YEAR 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient 0 DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Phyllis Bruce 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) in death) Sequentially list conditions, if any, leading to the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: b) coronary Artery Disease onset to deat4h Year DUE TO, OR AS A CONSEQUENCE OF: c) onset to death 2. SEX Male DAYS 21a. MANNER OF DEATH 0 Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 9e. APT. NO. 165. LICENSE NO. 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in P HTN 215. IF TRANSPORTATION INJURY GrlverlOperator ❑ Passenger Pedestrian ❑ Other (Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE' 3a. DATE OF DEATH (Mo., Day, Yr.) January 2 2017 b. DATE SIGNED (Mo., Day, Yr.) January 3, 2017 23c. TIME 09:20 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due la the cause(s) stated. (Signature and Title) Shawn S. Lawrence, MD 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES EI NO 25.010 TOBACCO USE CONTRIBUTE TO THE DEATH? Q YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shawn S. Lawrence, MD, 223 South E St, Broken Bow, Nebraska, 68822 28a. REGISTRARS SIGNATURE A I w "6_ a Sc. UNDER 1 DAY HOURS MINS. 8d. COUNTY OF DEATH Hall 3. DATE OF DEATH (Mo., Day, Yr.) January 2, 2017 6. DATE OF BIRTH (M3, D October 17, 1928 , Yri) 9f. ZIP CODE 68803 1 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) January 4, 2017 17b. Zip' Code 68801 ART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? YES ® t±10 21c. WAS AN AUTOPSY PERFORMED? ❑ YES I 1 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED' DEAD .. 24e. 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) 26b. WAS CONSENT GRANTED? i January 9, 2017 Not Applicable if 26a is NO LIVES ❑ NO 128b. DATE FILED BY REGISTRAR (MD, Day,. Yr.)