201801001 - Laserfiche WebLink

Browse

S T ATE OF NEBRASKA �. � ` e Inctistm 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 8/21/2017 LINCOLN, NE$R4SKA 201801001 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. "COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 7. SOCIAL SECURITY NUMBER 508 -30- 8112 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand island. Nebraska 8 b. FACILITY-NAME (If not institution, give street and number) O Saint Francis Medical Center t 8c. CITY OR TOWN OF DEATH (Include Zip Code) ° Grand Island 68803 9a RESIDENCE -STATE 1 Nebraska 9d. STREET AND NUMBER LL >, 1915 W. Waugh St. la 10a. MARITAL STATUE AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated; ;❑ Widowed ❑ Divorced ❑ Unknown w 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Delores A Heesch 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Gra i d Island. Nebraska 1. FATHER'S -NAME (First Middle, Last, Suffix) Albert Anderson E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 9 (Yes; No, or Unk.) NO 15. METHOD OF DISPOSITION E Burial ❑ Donation ❑ Cremation 0 Entombment Removal ;❑ Other (Specify) 14 death) Sequentially fist conditions, if '. any, IOad to thece lmted ;.,. on line a. Enter the UNDERLYING CAUSE tttisease or injury that initieted > the events reelrting m death) DUE TO, OR AS A CONSEQUENCE OF: t.AST d) iY W U 0. IF FEMALE: ❑ Not pregnant within Past year ❑ Pregnant at time of death Not pregnant, but pregnant within 42 days of death ❑ ..: Not pregnant Out pregnant 43 days to 1 year before death ❑ Unknown H pregnant wdhtn Me past year E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 U d 22d, INJURY AT WORK? ❑ YES NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 22e. DESCRIBE HOW INJURY OCCURRED DATi. O F DE .T6i (Mo., Day, Yr.) Jant,Iary 29,! 2010 :DATE SIGNED (Mo., Day, Yr.) January 29, 2010 9d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Ryan Rarnaekers, MD 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Kevin Wood DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: c) 22b. TIME OF INJURY 23c. TIME OF DEATH 02:55 AM 5a. AGE - Last Birthday 5b. UNDER 1 YEAR (Yrs.) MOS. 78 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA 90. CITY OR TOWN Grand Island 10b. NAME OF SPOUSE (First, Garland J Heesch l; 42. MOTHER'S -NAME (First, Middle, Olga Harps 14a. INFORMANT -NAME Garland J Heesch 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island City Cemetery Grand Island DAYS 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 Middle, Last, Suffix) If wife, give maiden name 16b. LICENSE NO. 1325 CAUSE OF DEATH (See instructions and examples) ART i. Enter the: chain of eve ts- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, rai pIratoryartuat or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ime. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Esophageal Cancer diseass or condition roautting 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in P FEMUR FRACTURE 21b. IF TRANSPORTATION INJURY 0 Driver /operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES Ea NO ❑ PROBABLY ❑ UNKNOWN ❑ YES E/ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan Ramaekers, MD, 11111 S 84th Street, Papillion, Nebraska, 68046 [ 28a . REGISTRAR'S SIGNATURE Maiden Surname) February 1, 2010 3. DATE OF DEATH (Mo., Day, Yr.) January 29, 2010 6. DATE OF BIRTH (Mo., Day, Yr.) September 30, 1931 ❑ Hospice Facility 9g. INSIDE CITY LIMITS El YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day,Yr.) February 1, 2010 STATE Nebraska 17b. Zip Code 68803 APPROXIMATE INTERVAI, onset to death 2 Years onset to death onset to death onset to death ART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 4 NI? 21c. WAS AN AUTOPSY PERFORMED? ^ ❑ YES E NO • 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH ? :.. ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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 Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ to 28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.) 21P CODE