201801851 - Laserfiche WebLink

Browse

1. DECEDENTS -NAME (First, Middle, Last, Suffix) Robert Edwin Porter 4. CITY AND TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Des Moines, Iowa 5a. AGE Last Birthday (Yrs.) 71 5b. UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) December 19, 2017 March 30, 1 6. DATE OF BIRTH (Mo., Day, Yr.) 946 9a RESIDENCE-STATE Nebraska 9d. STREET AND NUMBER 2807 Stagecoach Circle 10a, MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑Married, but separafed ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) Yes 01/30/1964 15.METHOD OF DISPOSITION III Burial ❑ Donation El Cremation ❑ Entombment ❑ ReMoval ❑ other (specify) 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Not Embalmed 9c. CITY OR TOWN Grand Island 18. PART I. Enter the chainor events- - diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, re spiratory arrest, of 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) Cardiogenic Shock dion - n or condition resulting 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 1 Ob. :NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden n Karen Sue Roejke 0 11. FATHER'S *NAME (First, Middle, Last, Suffix) James Roy Porter 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Wilma LaVon Hawkins 14a. INFORMANT - NAME Karen Sue Porter b. LICENSE NO. l7a FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) AU Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo„ Day, Yr.) December 22, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon N STATE ebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) APPROXIMATE! E AL onset to death Minutes rx 0 o , IA Medial Center I 8c. CITY OR TOWN OF DEATH (Include Zip Code) n Omaha 33 LU a W U 7. SOCIAL SECURITY NUMBER 491 -54- 1670 811 FACILITY - NAME (If not Institution, give street and number) i Enter the UNDERLYING CAUSE (disease or injury: that initiated tleath): DUE TO, OR AS A CONSEQUENCE OF: c)Alveolar Hemorrhage onset to death Days theevenes LAST resulting in DUE TO, OR AS A CONSEQUENCE OF: d)Acute Respiratory Distress Syndrome? 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 H pregnettt within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d.1NJ URY AT WORK? DYES ] E 22b. TIME OF INJURY 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Adenocarcinoma Of Lung, Pleural Effusion, Abdominal Aortic Aneurysm 21a. MANNER OF DEATH ® Natural El Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 2113, IF TRANSPORTATION INJURY D Driver /Operator ❑ Passenger 0 Pedestrian ❑ Other (Specify) onset to death Days 19. WAS MEDICAL EXAMINER OR CORONER. CONTACTED? ❑ YES 611 NO 21c. WAS AN AUTOPSY PERFORMED? El YES ❑ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF. DEATH? ❑YES INO 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE in deathl k I. 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 1/4/2018 LINCOLN, NEBRASKA Sequentially list conditions, if any, leadIns to the cense linytd • 23a. DATE OF DEATH (Mo., Day, Yr.) December919, 2017 3b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH December 29, 2017 06:53 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causets) stated. (Signature and Title) Craig A Piquette, MD 25.:>DID TOBACCO US CONTRIBUTE TO THE DEATH? E ❑ NO ❑ PROBABLY ❑ UNKNOWN ry/AQ ur : ynU. , ....r ::, �,V ., 4Yl a:,t a,1l. .44e0 llj� STATE OF NEBRASKA ,? 201801851 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DUE TO, OR AS A CONSEQUENCE OF: b)Respiratory Failure ® YES 8a. PLACE OF DEATH HOSPITAL El Inpatient ___ OTHER ❑ Nursing Home /LTC ❑ ER /Outpatient ❑ Decedent's Home ❑ DOA 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Craig A. Piquette, MD, 4101 Woolworth Ave, Omaha, Nebraska, 68105 STANLEY COOPER ASSISTA � STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 8d. COUNTY OF DEATH Douglas 24a. DATE SIGNED (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 N ❑ Other (Specify) 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 Title) 26b. WAS CONSENT GRANTED Not Applicable if 26a is NO ❑ YES Hospice Facility 24c, PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD NO 28b. DATE FILED BY REGISTRAR (MO:, Day, Yr..)< January 2, 2018