|
STATE OF NEBRASKA
<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 />5/31/2017
<br />LINCOLN, NEBRASKA
<br />201705535
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />RaeAnn Saunders
<br />4. CITY:AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508 -78 -2004
<br />8b. FACILITY -NAME (If not Inst g street and number)
<br />CHI Health St. Francis
<br />9a, RES1DENCESTATE
<br />Nebraska
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No or Unk.) NO
<br />15. METHOD OF DIS POSITION
<br />E Burial 0 Donation
<br />❑ Cremation ❑ Entombment
<br />0 Removal Other(Specify)
<br />20. IF:FEMALE:
<br />Not pregnant Within past year
<br />❑ Pregnant at time of death
<br />•© Not pregnant but pregnant within 42 days of death
<br />❑
<br />!No pregnant, but pregnam 43 days to 1 year before death
<br />❑ Unknown if pregnant Withltlihe past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY ATWORK ?.
<br />❑YES ❑NO
<br />24. DATE QF DEATH (Mo., Day, Yr.)
<br />May 19 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 22, 2017
<br />d. To the best of my knowledge, death occurred at tl.e time, date and glace
<br />and due to the cause(s) stated. (Signature and Title)
<br />Ryan D. Crouch, DO
<br />22b. TIME OF INJURY
<br />23c. TIME OF DEATH
<br />07:35 AM
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />60
<br />9b. COUNTY
<br />Hall
<br />25. 011) TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES I NO ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska
<br />1 284 REGISTRAR S SIGNATURE a
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9d. STREET AND`NUMBER
<br />4079 Cannon Road
<br />DAYS
<br />9e. APT. NO.
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />9C. CITY OR TOWN
<br />Grand Island
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name::..
<br />Raymond M Saunders
<br />11. FATHER'S -NAME (First; Middle, Last, Suffix)
<br />Ronald Campbell
<br />1 < 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Evelyn Morosic
<br />14a. INFORMANT-NAME -:
<br />Raymond M Saunders
<br />16a. EMBALMER- SIGNATURE
<br />Makavla McVey
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)i'd
<br />ADfel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions
<br />Cerebral Vascular Accident
<br />contributing to the death but not resulting in the underlying cause given in PART I.
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could net be determined
<br />16b. LICENSE NO.
<br />1499
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Diver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other fSPecify)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 19, 2017
<br />6. DATE OF BIRTH (Mo.
<br />February 6, 1957
<br />Day, yr.)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />28b. DATE FILED BY REGISTRAR {Mo.i
<br />May 24, 2017
<br />9g. INSIDE CITY LIMITS''
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Days Yr.)
<br />May 23, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />St. Marv's Cemetery
<br />CITY / TOWN
<br />Wood River
<br />STATE
<br />Nebraska
<br />17h, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />•19, PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death.DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or yentricylar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Acute Abdomen
<br />disease or condition resulting
<br />APPROXEMATEINTERVAL
<br />onset to death
<br />10 Days
<br />Sequentially list condition10f
<br />any, lei dingtdthe cause (iwr4d
<br />on line e
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Intestinal Ischemia
<br />onset to death
<br />10 Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(t(isea8g or m)ury that initiated
<br />onset to death
<br />the events result] in death:)
<br />LASY
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ENO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />CITY /TOWN
<br />STATE
<br />ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNC DEA
<br />24e. CM the basis of examination andsor investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />
|