|
AWICatr
<br />a
<br />` ��.�rxi� y 'l,rt
<br />DOUGLAS COUNTY
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF DOUGLAS COUNTY, NEBRASKA, IT CERTIFIES THE
<br />DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE DOUGLAS COUNTY
<br />HEALTH DEPARTMENT, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />201700749
<br />DATE OF ISSUANCE ADI POUR HEALTH DIRECTOR
<br />01/30/2017 DOUGLAS COUNTY HEALTH
<br />OMAHA, NEBRASKA DEPARTMENT
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />U
<br />0
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Sallie S Folsom
<br />4, CITY: AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Des Moines, Iowa'
<br />7. SOCIAL SECURITY NUMBER
<br />525 -70 -1202
<br />$b, FACILITY -NAME (If not Institution, give street and number)
<br />1620 North 56th Street
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />86
<br />9b. COUNTY
<br />Douglas
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />MOS.
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68104
<br />9d. STREETAND
<br />1620 North 56th Street
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married
<br />[ Married, but separated, ❑ Widowed ❑ Divorced ❑ Unknown
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) NO
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation ❑ Entombment
<br />Removal ❑ Other (Specify)
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />4.! Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJ AT WORK?
<br />4«I Y ND
<br />23a, DATE OFDEATH (Mo., Day, Yr.)
<br />Jaftuary 10.:2017
<br />23b DATE SIGNED (Mo., Day, Yr.)
<br />January 27. 2017
<br />2 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />DYES LE NO ❑ PROBABLY ❑ UNKNOWN
<br />16a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />22b. TIME OF INJURY
<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 />enda Keifer, MD
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />23c. TIME OF DEATH
<br />08:30 AM
<br />Sb. UNDER :1YEAR
<br />DAYS
<br />HOURS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />90. CITY OR TOWN
<br />Omaha
<br />9e. APT. NO.
<br />28a. REGISTRAR'S SIGNATURE
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MINS.
<br />9f. ZIP CODE
<br />68104
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />John D Folsom
<br />1 1. FATHER'S -NAME (First,' Middle, Last, Suffix)
<br />Ralph Stark
<br />12. MOTHERS -NAME (First, Middle, Maiden Surname)
<br />Sadie Skoglund
<br />14a. INFORMANT -NAME
<br />John D Folsom
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Hoy Kilnoski Funeral Home and Crematory Council Bluffs
<br />STATE
<br />Iowa
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Chapel of Memories, 9001 Arbor Street #111. Omaha, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />c cife
<br />ta, PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only she cause an a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (final a) Heart Disease
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Years
<br />it death)
<br />equentially$ hat conditions, if
<br />any, leading 10 the cause listed
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Heart Failure
<br />onset to death
<br />Weeks
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Atrial Fibrillation
<br />(disease or injury that Initiated
<br />onset to death
<br />Months
<br />the events resening:: death)
<br />LASTi
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Severe Dementia
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />248, DATE SIGNED (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES
<br />24d. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 10, 2017
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 16, 1930
<br />9g. INSIDE CITY LIMITS •
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />January 12, 2017
<br />17b. Zip Code
<br />68124
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />I YES © NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF
<br />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
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<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 Title)
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO ,
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Brenda Keller, MD, 10060 Regency Circle, Omaha, Nebraska, 68
<br />28b. DATE FILED BY REGISTRAR (Mo,, Fay, Yr.)
<br />January 27, 2017
<br />
|