201702368 - Laserfiche WebLink

Browse

y 8 l ` tilt ,Chi a ..at V J Y e : r;v " STATE OF NEBRASKA AA". 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 OP ISSUANCE 8/2/2016 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ronald Eugene Obermeier CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 508 -48 -1892 8b. FACILITY -NAME (Knot institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 a. RESIDENCE -STATE 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 409 Hillside Drive Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married Married, but separated', ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ben Obermeier 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes ` 11/29/1957-06/01/1958 15. METHOD OF DISPOSITION Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other(Specify) IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure dl<? =s2 c d x:nr. a i'•mg 1 in death) Sequentially list •cr3 Yditi0 s, if any, leading to the.tause tilted • on linea. _. __.. Enter the UNDERLYING CAUSE (disease 9r injury - .that initiated the events resuitmg in death) LAST 20. IF FEMALE: ❑ Not pregnant WIthtn past year ❑ Pregnant at tim of death ❑ Notpregnard •but pregnant within 42 days of death ❑ Not pregnant, but pregnant43 days to 1 year before death ❑unknown if pregnant within :the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2d. INJURY A7 :WORK?; ',❑ YES •❑ NO 23a. DATE QF DEATH (Mo., Day, Yr.) July 15, 2016 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 16a. EMBALMER-SIGNATURE Westlawn Memorial Park Cemetery DUE TO, OR AS A CONSEQUENCE OF: b) Pneumonia (Yrs.) DUE TO, OR AS A CONSEQUENCE OF: c) Chronic Obstructive Pulmonary Disease DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH JuI. 2 2016 i 'i :23 AM 3d. To the best of my knowledge, death occurred at the time, date and Mac and due to the cause(s) stated. (Signature and Title) Ryan D, Crouch, DO ...... ........ .............. ...... ........ ....... ....... 201702368 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 76 MOS. 8a. PLACE OF DEATH HOSPITAL © Inpatient 0 ER/Outpatient ❑ DOA 9c. CITY OR TOWN Cairo 10b. NAME OF SPOUSE (First, Dorothy Hilmer 12. MOTHER'S -NAME (First, Nora Alcorn 14a. INFORMANT-NAME Dorothy Obermeier Gwen K. Hyronemus 16d. CEMETERY, CREMATORY OR OTHER LOCATION 17a. FUNERAL NOME NAME AND MA LING ADDRESS (Street, City or Town, State)' Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska CAUSE OF DEATH (See instructions and examples) F . PART I. Enter the chain of events - - diseases, injuries, or complications -that directly caused the death, 00 NOT enterterminal events such as cardiac arrest, ' APPROXIMATE.!INTERVAL. respiratory arrest, or ventricutar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. - -- 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 Chronic Renal: Failure ,congestive Heart Failure OR CORONER CONTACTED? ❑ YES IAI NO 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Couldnot be determined 25. <0(0 TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEE ❑ YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 8a, REGISTRAR'S SIGNATURE 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITYITOWN DAYS 9e. APT. NO. STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68824 Middle, Last, Suffix) If wife, give maiden name. 16b. LICENSE NO. 1448 CITY I TOWN Grand Island OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) Middle, Maiden Surnarne) STATE 24a. DATE SIGNED (Mo., Day, Yr.) CONSIDERED? MINS 3. DATE OF DEATH (Mo., Day, Yr.) July 15, 2016 6. DATE OF BIRTH (Mo. Da April 6 1940 ❑ Hospice Facility 9g. INSIDE CITY LIMITS ❑ YES ® NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) July 20, 2016 STATE Nebraska 17b. Zip Code 68803 24 Hours onset to death 48 Hours onset to death Chronic onset to Sled 21c. WAS AN AUTOPSY PERFORMEC ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24b. TIME OF DEATH ;> 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 Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo.,. bay, Yr.) July 25, 2016