201800405 - Laserfiche WebLink

Browse

STATE OF NEBRASKA +ffi w s '- 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 7/20/2016 LINCOLN, NEB, 201800405 STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH A. atri STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 16::D3975 7. SOCIAL SECURITY NUMBER 171 -40 -155.1 8b. FACILITY -NAME (If not Institution, give street and number) a :< F cv ce 8c. CITY OR TOWN OF DEATH (Include Zip Code) • Grand Island 68803 9a. RESIDENCE- STATE. 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 2816 West Cottage U- LL .0 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Donna Aleen Ellis 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Pittsburgh, Pennsylvania Tiffany Square Care Center at d 0 a 15. METHOD OF p+sPOSITION FO- ❑ Burial ❑ Donation E Cremation ❑ Entombment 0 RemoVal ❑ Other' (Specify) 20. IF<FEMALE: ® Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 41 days to I year before death ❑ Unknown [f pregnnt a wtthlh3h past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT IAtORK9 YES ❑NO 23a. DATE OF DEATH (Mo., Day, Yr.) W au)y 9, 2016! 23b. DATE SIGNED (Mo., Day, Yr.) July 11,2016 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ Yes ® NO ❑ PROBABLY ❑ UNKNOWN 5a, AGE(- Last Birthday (Yrs.) 69 51) UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9c, CITY OR TOWN Grand Island DAYS 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska CAUSE OF DEATH j3ee instructions and examples) 23c, TIME OF DEATH 06:35 AM 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. pignature and Title) Katie: L. Peters, APRN 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could notbe determined 28a. REGISTRAR'$SIGNATURE / a � j „ 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 3. DATE OF DEATH (Mo., Day, Yr.) July 9, 2016 Day, 6. DATE OF BIRTH (Mo., May 17, 1947 ❑ Hospice Facility e. APT. NO. 19f. ZIP CODE 68803 9g. INSfbE CITY LIMITS" ® YES ❑ NO 10e. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, bufseparated. i;❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Daniel Edward Ellis 11. FATHER'S -NAME (First Middle, Howard Wood Last, Suffix) f 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Nelda Fenner 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, Or unit.) No Daniel Edward Ellis 14b. RELATIONSHIP TO DECEDENT Husband 16a. EMBALMER- SIGNATURE Not Embalmed 1 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) July 11, 2016 Gibbon 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Weakness, Debility, Dementia, DM II, Anemia, Protein - calorie Malnutrition 21b; IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 2 ' PRONOUNCED DEAD (Mo., Day, Yr.) STATE Nebraska 17b. Zip Code 68801 DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death PART L Eater the Chain of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricyiar 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) Respiratory Failure disease or condition remitting +n death) DUE TO, OR AS A CONSEQUENCE OF: Se qua ur tr $ t con ditio n :, [r ;b)Abdominal Sepsis Secondary To Perforated Colon an y, lead ing ti th e c ause listed on line a APPROXIMATE /NTERVAI. onset to death: Hours onset to death `> Days iha evtEtt LAST resillti DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22b. TIME OF INJURY 122c. 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. CITY /TOWN STATE ° ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCEDiDEAD 24e. On the basis of examination and /or investiga ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tide) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO DYES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Katie L. Peters, APRN, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,) July 14, 2016