201702164 - Laserfiche WebLink

Browse

DATE OF ISSUANCE STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALMVANb H UMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS 4 RTh.l (T, OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR }/X11,,RECQADS,' 201702164 . STANL�E S. COOPER ;ASSTS f4NT,aS7T " REGIS t f3E'PAR ME OF HEALTH AND LINCOLN, NEBRASKA '»MAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE CERTIFICATE OF DEATH 01/11/2016 15 07704 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Robert Conrad Larson 2. SEX Male 3: DM (Mo., Day, Yr.) -. -Qeeember 23, 2015 To be completed by: CERTIFIER I I To be completed /verified by: FUNERAL DIRECTOR 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Shickley, Nebraska 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) 95 MOS. DAYS HOURS MINS. January 21, 1920 7. SOCIAL SECURITY NUMBER 508 - 14-1983 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Wood River 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Cairo 9d. STREET AND NUMBER 410 S. Sycamore 9e. APT. NO. 9f. ZIP CODE 68824 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Ruth Sorensen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Olaf Larson 12. MOTHER'S -NAME (First, Middle, Malden Surname) Augusta Samuelson 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 01/10/1942-12/29/1945 14a. INFORMANT -NAME Ruth Larson 14b. RELATICINE HIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION IE Burial ❑ Donation ❑ Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Matthew T. Myers 16b. LICENSE NO. 1411 16c. DATE (Mo., Day, Yr.) December 28, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Mt. Pleasant Cemetery Cairo Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of e ants -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory 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: onset to death IMMEDIATE CAUSE (Final a) Respiratory Failure < 1 Month disease or condition resulting n death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b)Alzheimers Dementia > 1 Year any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST d) 18. PART I I . OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death ' . not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 12,1 NO 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 pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES gi NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b, TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE a i 0 W z le 23a. DATE OF DEATH (Mo., Day, Yr.) December 23, 2015 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 7, 2016 23c. TIME OF DEATH 09:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 2 < O 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) Jennifer L. Brown, MD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the causels) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE • 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 7, 2016 DATE OF ISSUANCE STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALMVANb H UMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS 4 RTh.l (T, OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR }/X11,,RECQADS,' 201702164 . STANL�E S. COOPER ;ASSTS f4NT,aS7T " REGIS t f3E'PAR ME OF HEALTH AND LINCOLN, NEBRASKA '»MAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE CERTIFICATE OF DEATH 01/11/2016 15 07704