201706483 - Laserfiche WebLink

Browse

V,; )('' ' Okriatik , dillitattV 4 thtkititliNOJ dibitia.■\ "' v 7:iiiiktU, N,'S STATE OF NEBRASKA * *111/4 46w Penialtri - 111.4 - 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 2 0 1 7 0 6 4 8 3 8/9/2017 LINCOLN NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES CC UI I 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Judith Ann Katzberg 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 506-62-2135 8b. FACILITY-NAME (If not InStitut)on, give street and number) 4080 Cannon Rd 9a. RESIDENCE-STATE Nebraska 10a, MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (yes, No, or Unk.) NO 15. METHOD OF DISPOSITION 0 Burial ria Donation 0 Cremation 0 Entombment 0 Removal 0 Other (Specify) Enter the UNDERLYING CAUSE 011Sease of injury that initiated the event result ng lit death) LAS P. IF Fpri4Let El Not pregnant Within past year 0 Pregnant at time of death Not but oregnantwithin 42 days of death NOppregrieetiputpregrient 433lays tot year before death 0 Unknown If pregnant Within the past year • 22a. DATE OF INJURY (Mo., Day, Yr.) . 220. INJURY AT WORK? DYES... ONO 23e (Mo., Day, Yr.) >.J 017 ph:PATeelotecr(mo., Day, Yr.) August 8, 2017 22b. TIME OF INJURY 23c. TIME OF DEATH 05:25 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the tassels) stated. (Signature and Title) Gary Settie, MD 25. =TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES El NO 0 PROBABLY 0 UNKNOWN 28a. REGISTRAR'S SIGNATURE J� I ait , 5a. AGE - Last Birthday (Yrs.) mos. 68 9b. COUNTY 1-la ll 51). UNDER 1 YEAR 9d. STREET AND NUMBER 4080 Cannon Rd 16a. EMBALMER-SIGNATURE Beniamin Hall 21a. MANNER OF DEATH Natural 0 Homicide Accident D Pending Investigation Suicide 0 Could not be determined DAYS 8a. PLACE OF DEATH HOSPITAL 0 Inpatient O ER/Outpatient 0 DOA 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 HOURS 9e. APT. NO. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? DYES El NO 2. SEX Female Sc. UNDER I DAY MINS. OTHER 0 Nursing Home/LTC 0 Decedent's Home 0 Other (Specify) 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) July 10, 2017 6. DATE OF BIRTH (Mo., Day, yr.} December 14, 1948 0 Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 8g. INSIDE CITYUMITS [id YES 0 NO lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Darwin Dean katzlDerci 11. FATHER'S-NAME (First, Middle, Last, Suffix) Hubert Linden 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Opal Groenewold 14a. INFORMANT-NAME Darwin Dean Katzberq 16b. LICENSE NO. 1305 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 14b. RELATIONSHIP TO .DECEDENT Husband 16c. DATE (Mo., Day, Yr.) July 13, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN Nebraska Anatomical Board Omaha STATE Nebraska 17b. Zio Code 68801 CAUSE OF DEATH (See instructions and examoles) 14, PART L Enter the chain of events- -diseases, Injuries, or complications-that directly caused The death. DO NOT enter terminal events such as cardiac arrest, respirator), arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on 0 line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Metastatic Neuroendocrine Cancer IMMEDIATE CAUSE (Final disease or condition resulting APPROXIMATE INTERVAL, onset to death 3 Years death) Sequentially (let rontlitiorm, it any, leading to the Cause listed on line it DUE TO, OR AS A CONSEQUENCE OF: b)Primary Tumor - Unknown Primary onset to death DUE TO, OR AS A CONSEQUENCE OF: c) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS contributing to the death but not resulting in the underlying cause given in PART I. 21 b. IF TRANSPORTATION Driver/Operator 0 Passenger 0 Pedestrian 0 Other {Specify) INJURY 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? DYES al }id 21c. WAS AN AUTOPSY PERFORMED? 0 YES 0 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? DYES Owe 22c, PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DE.AD 24e. On the basis of examination andlor Investigation, in my opinion death occurred at the time, date and place and due to the tassels) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO DYES D NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Settje, MD, 2116W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR iNto., Day, Yr,) August 8, 2017 CD (C)