201705357 - Laserfiche WebLink

Browse

To be completed1verified by: FUNERAL DIRECTOR j 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Kelly Kay Stoppkotte 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) February 7. 2017 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lexington, Nebraska Sa. AGE Last Birthday (Yale) 48 Sb. UNDER 1 YEAR 5c. UNDER I DAY 0. DATE OP BIRTH (Mo., Day, Yr.) August 27, 1970 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 - 15 - 2770 Ss PLACE OF DEATH HOSPITAL ® Inpatient OTHER 0 Nursing Home&LTC ❑ Hospice Facility Bb. FACIUTY•NAME (If not Institution, give street and number) CHI Health St. Francis ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) Sc. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 Sd COUNTY OF DEATH Hall Sa. RESIDENCE Nebraska Sb. COUNTY Merrick Sc. CITY OR TOWN Chapman Sd. STREET AND NUMBER 447 H. Road W. APT. NO. W. ZIP CODE 68827 9g. INSIDE CITY LIMITS ❑ YES Oa NO 10a. MARITAL STATUS AT TIME OF DEATH ) Married ❑ Never Married MIMEO. Dot separated ❑ Widowed ❑ Divorced ❑ Unknown J 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) N wife, give maiden name Michael Stoppkotte I1. FATHER'S.NAME (First, Middle, Last, Suffix) Paul Linn ` 1 2 MOTHER'S-NAME (First, Middle, Malden Somme) Young 13. EVER IN U.S. ARMED FORCES? Give dates of service It Yes. (yea, No, or Unk.) No t4a. INFORMANT.NAME Michael Stoppkotte 14b. RELATIONSHIP TO DECEDENT Spouse 1S. METHOD OF DISPOSITION ❑ aerial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER Tracey Dietz 15b. LICENSE NO. 1328 1EO, DATE (Mo., Day, YL) February 11, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a, FUNERAL HOME NAME AND MAIUNO ADDRESS (Slreel. City or Town, State) Aofel Funeral Home. 1123 W. 2nd, Grand Island. Nebraska 17b. Zip Code 68801 I CAUSE OF DEATH (See instructions and examolesl To be completed by: CERTIFIER IS. PART L.ERNI.. cMN Nev em. draws, Nunes. or compic1000 -0W dinchy coated the death. DO NOT enter nominal events arch as Cardiac ammo APPROXIMATE INTERVAL onset to death Days raspiney anal, at vomdctac toniaslbn *Wow showing the etiology, 00 NOT ABBREVIATE NW only line pane en a M. Add 000010ml Sirs it mammy. IMMEDIATE CAUSE: aauEDIATECAUSe{Fna a) Multi system Organ Failure dials• Of cdndtIdn rooting in stunt DUE TO, OR AS A CONSEQUENCE OF: onset to death eaeuem4Uy ate conditions.* b) Metastatic Uterine Leiomyosarcoma Months any. leading to the tease Wed CM Meat DUE TO, OR AS A CONSEQUENCE OF: Onset to death enter dal UNOERLYINO CAUSE C) Idewe• OWN °, OW kaen•d er ewae MUpbq n daathl DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18, PART IL OTHER SIGNIFICANT CONDITII iom contributing to the death but not restating in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®. NO 20. IF FEMALE: El Ha iy,wenNA within now year w al ton ❑ Pngne a death ❑ N .. * Rol PRprnt Within 42 days ol date ❑ lea PRIPM, but mom. a days to / year Dem death ❑ unknown B w+wms within the Past year 2 MANNER OF DEATH El Natural ❑H«made ❑ Accident ❑ Pending pangatlan co. ❑ swum ❑ nit be dsnombrd 21b. IF TRANSPORTATION INJURY ❑ 5.10 OPnns ❑ PnNnpn ❑ AMNO.n ❑ Met (SIMIn l 2Ic. WAS AN AUTOPSY PERFORMED? ❑YES ® 1d. WERE AUTOPSY FINDINGS AVAILABLE 2 TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Moo, Day, Yr.) 22b. TIME OF INJURY 220. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc (Specify) 22d. INJURY AT WORK? OYES ONO 22s. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY STREETS NUMBER, APT.NO. CITYITOWN STATE ZIP CODE a t o ' 23a. DATE OF DEATH (Mo., Day, Yr.) February 7, 2017 AVID ANNeOAAY A11111030 NVI]ISANd SOHO 24. DATE. SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 231., DATE SIGNED (Moo, Day, Yr.) February 8, 2017 J 23e. TIME OF DEATH 10:29 AM Soc. PRONOUNCED DEAD (MO, Day, Yr.) 24d TIME PRONOUNCED DEAD E . M. To the lien any haresdede., dens, xtwrw dm. dm and pac• and aa. to Ora musemi smart Mienamrs and MN Chad Vieth, MD VA. 0411M basis a w rdnaton andbt anenignbn,n rib opiniondasN occ umdM Ns twit, dab and pap and dor to the coeeetel sbte0 (Bbwbae and TIAN 25.010 TOBACCO. USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 2Ea. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES Ea NO 2N0. WAS CONSENT GRANTED? Not Appauae If Sea Is NO ❑ YES ❑ NO 27. NAME. TITLE AND ADDRESS OF CERTIFIER (Typo or Print) Chad Vieth, MD, 2116 W Fa)dley #400, Box 9802, Grand Island, Nebraska, 68803 1264. REGISTRAR'S SIGNATURE ►' /( 4 211b. DATE FILED BY REGISTRAR Gan., Day, Yr.) February 15, 2017 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 Y N STANLEY S. COOPER DATE OF 20 ISSUANCE 201705357 DEPARTMENT HEALTH AND AR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH LINCOLN, NEBRASKA STATE OF NEBRASKA . __ 17 02021