201700927 - Laserfiche WebLink

Browse

2 }�lli ;p t , t . lit�' aS STATE OF NEBRASKA 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 1/18/2017 LINCOLN, NEBRASKA 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated O Widowed ❑ Divorced ❑ Unknown 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Bette Jean McComb 4- CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Joseph, Missouri 7. SOCIAL SECURITY NUMBER 506 -40 -2493 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health.:St. Francis re 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 - 9s ':IEI 9d. STREET AND NUMBER 316 Commanche Ave. -a 4 11. FATHER'S -NAME (First, Middle, Last, Suffix) a Clayton Millspaugh . RESIDENCE -STATE Nebraska E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. u (Yes, No, or Ursk.) NO 15. METHOD OF DISPOSITION 12 ❑ Burial -❑ Donation Cremation ❑ Entombment ❑.: Removal 0 Other (Specify) 5a. AGE • Last Birthday (Yrs.) 78 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed 5b. UNDER 1 YEAR DAYS MOS. HOURS 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ Eft/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 3d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand! Island 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY MINS. 9f. ZIP CODE 68801 3. DATE OF DEATH (Mo., Day, Yr.) January 6, 2017 6. DATE OF BIRTH (Mo. Day, Yr} February 5, 1 8 9g. INSIDE CITY LINITS< ® YES ❑ NO lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name James McComb 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Beulah White 14a. INFORMANT -NAME Alan Lynn McComb 16b.LICENSE NO. 17a. FUNERAL NOME NAME AND MA LING ADDRESS (Street, City or Town, State) Ali Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr) January 10, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 17b Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 48. PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death DO NOT enter terminal wrests such as cardiac arrest, respiratory arrest, or ventricyi 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) Sepsis With Septic Shock disease or condition resulting onset to death 5 Days APPROXIMATE'I NTERVAt,;. ...in death). Sequnntia6y list Conditions, it !> any, leading to the :cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: b) Pneumonia onset 10 dc+al 10 Days 0 V DUE TO, OR AS A CONSEQUENCE OF: C) onset to death Enter the UNDERLYING CAUSE /disease ar injury:tttat initiated. the events resulting m death) LAST; DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Acute Pulmonary Embolus, Acute Pancreatitis, Respiratory Failure With Hypoxia 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if poignant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) I 22b. TIME OF INJURY 22d. INJURY ATNORK? ❑ YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE" u z a 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH January 9, 2017 07:23 PM e 0 3d, To the best of my knowledge, death occurred at the time, date and place G and due to the cause(s) stated. (Signature and Title) l'8 Steven Husen, MD 23a. PATE OFRE■TH (Mo., Day, Yr.) January C20 25. BID TOBACCO USE CONTRIBUTE TO THE DEATH? YES NO ❑ PROBABLY ❑ UNKNOWN 28a. REGISTRAR'S SIGNATURE 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 21 b. IF TRANSPORTATION INJURY OnlverlOperator ❑ Passenger ❑ Pedestrian Other. (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES QNO )6- - 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES` E ...... ...... .. . 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES 0 N 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 causes) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven H MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 January 12, 2017 28b. DATE FILED BY REGISTRAR (Mo. Day Yr.} 20170092'7 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Coe STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES