201801238 - Laserfiche WebLink

Browse

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 2/5/2018 LINCOLN, NEBRASKA 201801238 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AN CERTIFICATE OF DEAT ,8b. FACILITY -NAME (If not Institution, give street and number) O 4227 Indianhead Rd., 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 cc • 9a. eesioENLE ^STAL 9b. COUNTY tu • Nebraska Hall D 9d. STREET AND NUMBER ,, 4227 Indianhead Rd., 10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married Q Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown :.E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Utk.) (VD 2 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal :Q Other (Specify) 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Marion North 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH I5a. AGE - Last Birthday (Yrs.) Imperial, Nebraska 67 7. SOCIAL SECURITY NUMBER 507 -66 -4507 in death) Sequentially fist tondihons if b) any, leading to the pause listed on line a. Enter the UNDERLYING CAUSE (disease or mtury:that idldkied suiting in death) 20. IF FEMALE: ❑ Not pregnant within Oast year ❑ Pregnant at time of death ❑ Not pregnant,Ibut pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown d pregnant whhln the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d, INJURY AT: )ORK/ AYES ❑NO DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: C) 23a. DATE OF DEATH (Mo., Day, Yr.) PS January 20 2018 I . 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH .4' I z January 23, 2018 12:00 PM a O 3d. To the best of my knowledge, death occurred at the time, date and place 2 o and due to the cause(s) stated. (Signature and Title) IS i Adam Brosz, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES Ea NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Adam Brosz, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /t 21a. MANNER OF DEATH Natural ❑ Homicide 0 Accident 0 Pending Investigation ❑ Suicide ❑ Could not be determined 613. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL 0 Inpatient O ERlOutpatient ❑ DOA 9c. CITY Ok TOWN Grand Island 16a. EMBALMER - SIGNATURE Not Embalmed DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC ® Decedent's Home ❑ Other (Specify) d a 11. FATHER'S-NAME (First, Middle, Last, Suffix) Harry North 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mattie Redden 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Karen Kahout 14a. INFORMANT -NAME Karen North 1fb. LICENSE NO. 97a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Parkinsons Disease, Peripheral Vascular Decease, COPD, Cerebrovascular Disease, Carotid Artery Disease, Left Foot Drop, Osteoarthrltis, Spinal Stenosis 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger Pedestrian ❑ Other(Specify) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® N 3. DATE OF DEATH (Mo., Day, Yr.) January 20, 2018 August 5, 1950 6. DATE OF BIRTH (MO., Day, Yr,) 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) January 24, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 1713, Zip Cod 68801 CAUSE OF DEATH (See instructions and examples) 3. PART I. Enter the cheese* events- - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, Or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Community Acquired Pneumonia & Urinary Tract Infection disease or condition resulting APPROXIMATE INTERVAL onset to death 2 Weeks onset<to death` onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 10 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 220. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 24a, 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 Tide) 26b. WAS CONSENT GRANTED/ Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (M4 , Day, Yr.) January 25, 2018 . O HUMAN SERVICES H' STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES N 00 CD W