201706979 - Laserfiche WebLink

Browse

STATE OF NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Marsha Kay Truell 4. CITY AND STATE ct C 6 C 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 7/12/2017 LINCOLN, NEBRASKA SheIlAr Iowa 7. SOCIAL SECURITY NUMBER 482 -62 -2765 8b. FACILITY - NAME (If not Institution, give street and number) CHI Health St; Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand. Island 68803 9a. RESIDENCE - STATE Nebraska 9d. STREET AND NUMBER 1740 South Ingalls Street 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ❑ Widowed ® Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ernest Kiesel 3. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT-NAME (Yes, ND, or Unk.) No Jonathan Hamilton Truel( 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation E Cremation ❑ Entombment ❑ ;❑ other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska 18. PART 1. Enter the c respiratory arr IMMEDIATE CAUSE (Final . disease or condition resulting in death Sequent,allytistconditions, if any teadiagto the cause Ssted on line Enter the UNDERLYING CAUSE (disease or injury that inhiated the events teauldn9 in death) LAST; .. .. 2 IF FEMALE E Not pregnant Within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, a but pregnant 43 days to 1 year before death ❑ ilnk sown it pregnant.withIn the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑NO 23a. DATE OF DEATH (Mo., Day, Yr.) 1 Jtliy V 2017 23b. DATE SIGNED (Mo., Day, Yr.) July 7, 2017 RRITORY, OR FOREIGN COUNTRY OF BIRTH 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed IMMEDIATE CAUSE: a) Respiratory Failure DUE TO, OR AS A CONSEQUENCE OF: b) Encephalopathy DUE TO, OR AS A CONSEQUENCE OF: c) Cardiac Arrest DUE TO, OR AS A CONSEQUENCE OF: d) E Coli Sepsis 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 23c. TIME OF DEATH 12:25 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Isaac J. BerqMD 28a. REGISTRAR'S SIGNATURE 201706979 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 5a. AGE - Last Birthday (Yrs.) CITY /TOWN 68 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5b. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL E Inpatient ❑ ER/Outpatient 0 DOA 9c. CITY OR TOWN Grand island DAYS STANLEY S. • OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 8d. COUNTY OF DEATH Hall e. APT. NO. 16b. LICENSE NO. CAUSE OF DEATH (See instructions and examples) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN ❑ YES E NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print - Isaac J. Berg, MD., 729 North Custer Avenue, PO Box 2339, Grand island, Nebraska, 68803 2. SEX Female HOURS 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 5c. UNDER 1 DAY MINS. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger Pedestrian Other($pecify) OTHER ❑ Nursing Home /LTC ❑ Decedent's Home 0 Other (Specify) 9f. ZIP CODE 68803 evens - diseases, injuries, or complications -that directly caused the death. DO NOT enter tenninal events such as cardiac arrest, mritular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a 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 I 3. DATE OF DEATH (Mo., Day, Yr.) July 6, 2017 6. DATE OF BIRTH (MO., Day, April 11, 1949 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden naflte 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mildred Bailey 9g. INSIDE CITY' LIMITS ® YES ❑ NO 14b. RELATIONSHIP; TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) July 7, 2017 STATE Nebraska 17b. zip Code 68801 APPROXIMATE INTERVAL onset to death 10 Days onset to dea 10 Days onset to death 10 Days onset to dent 10 Days 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 21c. WAS AN AUTOPSY PERFORMED ❑YES ENO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) STATE ZIP CODE . DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 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 ❑ YES 0 NO 28h. DATE FILED BY REGISTRAR Mo., Day, Yr.) July 10, 2017