201800178 - Laserfiche WebLink

Browse

WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE 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 09/22/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 201800178 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES'; CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT,OF HEALTH AND HUMAN SERVICES 15 05380 1. DECEDENTS -NAME (First, Middle, Last, Suffix) LaDonna May Jaeger 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) September 17, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH O'Neill, Nebraska 5a. AGE - Last Birthday (Yrs.) 71 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) May 1, 1944 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -56 -2295 Sb. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ❑ Nursing Home /LTC 0 Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) Sc. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Doniphan 9d. STREET AND NUMBER 209 W.Bartelt Avenue 9e. APT. NO. 9f. ZIP CODE 68832 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Allan Ray Jaeger 11. FATHER'S -NAME (First, Middle, Last, Suffix) Jacob Sandoe 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Frieda Benash 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Allan Ray Jaeger 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) September 18, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) ta. 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, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Hypoxic Respiratory Failure disease or condition resulting onset to death Days in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b)Aspiration Pneumonia 1 Days any, leading to the cause listed I on line a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death Enter the UNDERLYING CAUSE c) Nausea And Vomiting I Days (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: t onset to death LAST d) 1 t 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. History Of DVT And pulmonary embolism, History Of CVA, Dysphagia As Late Effect Of CVA, G- Tube Dependent, Nephrolithiasis, Prothrombin Gene Mutation, Hypertension, hemiplegia As Late Effect of CVA 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ® Not pregnant within past year ❑ Pregnant at time of death g ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide Accident Pending Investigation ❑ ❑ ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator Passenger ❑ Passen er ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 2213. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE o W F u i 23a. DATE OF DEATH (Mo., Day, Yr.) September 17, 2015 z e g g i D E a a i a E 5 D w z t he o O ~ a 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 17, 2015 23c. TIME OF DEATH 02:45 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD ° u � 0 a 3d. To the beat of my knowledge, death occurred at the time, date and place o C and due to the ca stated. (Signature nd Title) s Jay C. Anderson, MD 24e. On the bas of examination and/or investigation, in my opinion death occurred at the time d ate and place and due to causes) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE " ` ��- _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I September 17, 2015 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE 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 09/22/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 201800178 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES'; CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT,OF HEALTH AND HUMAN SERVICES 15 05380