201703057 - Laserfiche WebLink

Browse

, 0 4 , ;(/ tuAy 100 tad et: fkk ce uJ W U 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 3/3/2017 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Merleen Jean Johnson 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH North Platte, Nebraska 7. SOCIAL SECURITY NUMBER 508 -26 -9297 8! > , FACILITY- NAME (If not institution, give street and number) •0 8 CHI Health St. Francis I t t l 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE 9b. COUNTY z Nebraska Hall LL 9d. STREET AND NUMBER 1808 West 2nd Street .0 s'C1 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married 1 E ❑ Married but separated ® Widowed ❑ Divorced ❑ Unknown v 11. FATHER'S -NAME (First, Middle, Last, Suffix) 1, George Frederick Geisert Q. 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 8 (Yes; Na, or Unk.) No .0 15. METHOD OF DISPOSITION 16a. EMBALMER- SIGNATURE 12 ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑Removal ❑ Other (Specify) Chris McCoy Blue Valley Cemetery (Yrs.) 14a. INFORMANT -NAME Brad Johnson 16d. CEMETERY, CREMATORY OR OTHER LOCATION 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) ADfel Funeral Home. 1123 W. 2nd. Grand Island, Nebraska IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting in death} Sequentially list cwtditions, if any, leading to the cause listed on line` a. DUE TO, OR AS A CONSEQUENCE OF: b)Multiple Myeloma DUE TO, OR AS A CONSEQUENCE OF: c) Enter the UNDERLYING CAUSE ( dsease et injury that initlatsd the events rest 0012,n death) : ; DUE TO, OR AS A CONSEQUENCE OF: LAST d) r O. IF FEMALE: in past year ❑ Not ❑ Pregnant at time of death ❑ Not pregnant; pregnant; pregnant within 42 days of death before death ❑ Not : but pregnsM 43 days to 1 y ❑ Unknown if pregnant w tfhi* The p ast year E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 V C 22d. INJURY AT1Al0 Li YES L.,J NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 25t. DATE OF DEATH (Mo., Day, Yr.) Februe 20 2017 23b. DATE stow) (Mo., Day, Yr.) 23c. TIME OF DEATH u z February 21, 2017 04:20 PM u a 0 3d. d0 the best of my knowledge, death occurred at the time, date and place ,S ;' and due to the causes) stated. (Signature and Title) o w P. Jennifer L. Brown, MD 28a. ItEG)STRAfRS SIGNATURE STANLEY S. COOPER 201703057 DEPARTMENT HEALTH AND REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 22e. DESCRIBE HOW INJURY OCCURRED 5a, AGE - Last Birthday 512. UNDER 1 YEAR CITY /TOWN 90 8a. PLACE OF DEATH HOSPITAL(] Inpatient ❑ ER/Outpatient ❑ DOA Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Robert James Johnson CAUSE OF DEATH (See instructions and examples) PART 1. Enter the chain Of events- - diseases, injuries, or complications -that directly caused the death. DO NOT enter temttnal events such as cardiac arrest, _. W:.__:,- Kb-.,,_. .........:............a,...,, nn NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary. 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Congestive Heart Failure 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) MOS.' 25. DID TOBACQQ USE CONTRIBUTE TO THE DEATH? ❑ YES tia NO 0 PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 CAVE ". CITY OR TOWN Grand Island" 12. MOTHER'S -NAME (First, Middle, I Treva Winifred Dressler zw DAYS 9e. APT. NO. 8d. COUNTY OF DEATH Hall 6b:: LICENSE 5/0. 1191 CITY i TOWN Ayr 2. SEX Female 5c. UNDER 1 DAY HOURS 9f. ZIP CODE 68803 21b. IF TRANSPORTATION INJURY 0 Oriver!Operator ❑ Passenger t ❑ � pedestrian t..t other (Specify) OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) MINS. 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN' CONSIDERED? ❑YES }MO Coe 6. DATE OF BIRT November 4, 1 Maiden Surname) onset 24b. TIME OF DEATH 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 0 YES 28b. DATE FILED BY REGISTRAR February 27, 2017 3. DATE OF DEATH (Mo., Day, Yr.) February 20, 2017 26 ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 4b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) February 25, 2017 STATE Nebraska 1 7b. Zip Code 68801 APPROXIMATE INTERVAL onset to death < 1 Week onset to dea > 1 Month onset to death (MO., Day, Yr) • 21c. WAS AN AUTOPSY PERFORMED9 ❑ YES ® NO 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED ? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑YES 0 N