201801449 - Laserfiche WebLink

Browse

S:Yekv %J35 x. �� ,a „ -® V■ ! a r V I I r v I l!l V I �/� $ q G4^N ✓y V r ,�.* cnAy - _98G 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 STANLEY COOPER 20 180144 DEPARTMENT HEALTHAND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 0 U " W 0 at ar a u 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) June M Quaife 4. CITYA ND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 507 -74 -5254 8b. FACILITY -NAME (If not Institution, give street and number) Nebraska Medicine 5a, AGE - Last Birthday (Yrs.) 63 5b. UNDER 1 YEAR M DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 68198 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 4172 Texas Avenue 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) NO 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Kealy M. Schilke 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) January 22, 2018 May 26, 1954 !` 6. DATE OF BIRTH (Mo., Day, Yr.) 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Douglas 9c. CITY OR TOWN Grand Island 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, , Middle, Last, Suffix) If wife, give maiden name Randy Quaife 11. FATHER'S -NAME (First, Middle, Walter Meyer Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Erlene Stauss Maiden Surname) 14a. INFORMANT -NAME Randy Quaife 16b. LICENSE NO. 1494 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Aofel Funeral Home, 1123 W. 2nd, Grand Island. Nebraska 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr) January 27, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Cameron Cemetery Wood River STATE Nebraska I7Ix zip cope 68801 CAUSE OF DEATH (See ingructionsind examples) II. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, respiratory anent, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Heart Failure IMMEDIATE CAUSE (Final disease or condition resulting APPROXIMATE INTERVAL onset to death Unknown in death) sequentially conditions, if any, leading to the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: b)Shock Enter the UNDERLYING CAUSE (disea or injury that initiated DUE TO, OR AS A CONSEQUENCE OF: C) onset to death the events tes4Iting in death LAST DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Retroperitoneal Hematoma 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 43 days to 1 year before death ® Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22d. INJURY AT.WORK? ❑yes []No ............. ...... ......... ............. ........ ....... 22f. LOCATION OF INJURY - STREET & NUMBER, APT,NO. CITY /TOWN STATE ZIP CODE da U � ° al 0 2 0 23 a. DATE OF DEATH (Mo., Day, Yr.) January 22 2018 23b. SIGNED (Mo., Day, Yr.) January 30, 2018 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) Ma Win U. Vora, MBBS 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 285. REGISTRAR'S SIGNATURE 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 05:09 PM 21b. IF TRANSPORTATION INJURY ❑ OriverlOperator ❑ Passenger Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN ORATION BEEN CONSIDERED? ❑ YES 10 NO 19, WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES J NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF 0 E ❑ YES ❑! No 24b. TIME OF DEATH 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 causes) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Maulin U. Vora, MBBS, 984455 Nebraska Medical Center, Omaha, Nebraska, 68198 28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.) February 2, 2018