|
t S R tt ' ∎,Y ;y A/ ,4. misoM, sit J. 4/ didtatU, t"
<br />STATE OF NEBRASKA
<br />to , ?x . ii
<br />CK
<br />LL
<br />w
<br />v
<br />0
<br />a
<br />n 0 z
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />7/18/2017
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Cynthia L Christenson
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kansas City, Missouri
<br />7. SOCIAL SECURITY NUMBER
<br />510 -56 -8643
<br />b. FACILITY -NAME (If not Institution, give street and number)
<br />Mary Laming g Healthcare
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Hastings 68901
<br />9a. RESIDENCE -STATE 9b. COUNTY
<br />Nebraska Adams
<br />9d. STREET AND NUMBER
<br />2900 Lake Park Lane
<br />13: EVER IN U. S: ARMED; FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />15. METHOD OF f31SPOEITit N
<br />❑ Burial ❑ Donation Not Embalmed
<br />® Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />22d. INJURY AT WORK?
<br />AYES C) NO
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Metastatic Pancreatic Cancer
<br />Mutate or condition resulting
<br />in death);;
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially tilt Condition, if i' b)
<br />anq,%acdir.,ry, in :Hs ;:Cause I1sF43:�i'
<br />on line a.
<br />DUE TO OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />,dlseasoor injury that lnitiated>:
<br />the evemsresulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />0. IF FEMALE:.::.
<br />gi Not pregnantwithin past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant but pregnant43 days to 1 year before death
<br />❑ unknown itpregnant Within the past year
<br />a. DA TE OF DEATH (Mo., Day, Yr.)
<br />March 6, 2015
<br />16a. EMBALMER-SIGNATURE
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />BV Cremation Center
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />3b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />March 6,2015 10:53 AM
<br />3d. 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 />Timtthv Zimmerman, MD
<br />8a. REGIBTRAf S SIGNATURE
<br />201704910 ASS S ANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />5a. AGE - Last Birthday Sb. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />61
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient OTHER ❑ Nursing Home /LTC
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />DOA ❑ Other (Specify)
<br />Ilia. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 19b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Eric ChristenSOn
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Charles Dingus Menelia Johnson
<br />14a. INFORMANT -NAME
<br />Eric Christenson
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livinoston - Butler - Volland Funeral Home. 1225 N. Elm, Hastings, Nebraska
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />CITY/TOWN
<br />c. CITY OR TOWN
<br />Hastings
<br />9e. APT. NO.
<br />8d. COUNTY OF DEATH
<br />Adams
<br />16b LICENSE NO.
<br />CITY) TOWN
<br />Hastings
<br />CAUSE OF DEATH (See instructions and examples)
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />MINS.
<br />9f. ZIP CODE
<br />68901
<br />a. PART I. Enter the chain of event -diseases, injuries, or complications -that directly caused: the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, orventrKalar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause lone line. Add additional lines if necessary.
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Otter (Specify)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />5. DID TO 000 USE CON TRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES tia NO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Timothy Z+mmerrnan, MD, 1021 W 14th St., P.O. Box 968, Hastings, Nebraska, 68902
<br />Coe
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 6, 2015
<br />❑ Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (Mo., Day, Yr.)
<br />March 8, 2015
<br />STATE
<br />Nebraska
<br />17b. Zip'Code
<br />68901
<br />APPROXIMATE I N TERVAL
<br />onset to death
<br />N/a
<br />onset to death
<br />onset to death
<br />onset tp death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES §11 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE.
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />24b. TIME OF DEATH
<br />STATE ZIP CODE
<br />S ¢ 11
<br />5 Si o
<br />w z 24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />$
<br />8 the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />rl
<br />24d. TIME PRONOUNCED DEAD
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR(Mo„ Day, Yr.)
<br />March 9, 2015
<br />
|