201802508 - Laserfiche WebLink

Browse

Mt 17 ay e x. u- W >' 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Patricia Lianne Bilsiend 4 . 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 10/18/2017 LINCOLN NEBRASKA CITY .AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Shelton, Nebr ask i 7. SOCIAL SECURITY NUMBER 505 -36 -2717 8b. FACILITY -NAME (If not Institution, give street and number) Wilb Car Center' 8c. C.IT ! OR TO :AN OF DEATY II :I lads Zip Code) Wilber 684.65 9a. RESIDENCE,STATE Nebraska 9d. STREET AND NUMBER 608 Ravenwood Drive 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, OM separated 'i ® Widowed ❑ Divorced ❑ Unknown } .0 11. FATHER'S-NAME (First, Middle, Last, Suffix) d Howard Felps 113. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 8 (Yes, No, or Unk.) Ng 15. METHOD OF DISPOSITION ° ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal 0 Other (Specify) 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, St Aofel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska 18. PART 1, Enterthee.Nain of respiratory arrest, orYentri IMMEDIATE CAUSE (Final disease or condition resulting in death) ., Sequaritially hst conic l ions, If any, leading to the chase 3lsted on inc - a. Enter the UNDERLYING CAUSE (disease or 'Null that in the events tasutti} death) LAST 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.) 2 DATE OF DEATH (Mo., Day, Yr.) October 9, 2017 74, WA::i Cot+ «D tilt.?., Day, Yr.) October 12, 2017 9b. COUNTY Hall 1Sa. EMBALMER - SIGNATURE Jeffrey R. Kuncl Wood River Cemetery DUE TO, OR AS A CONSEQUENCE OF: b) Coronary Artery Disease DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 1 22b. TIME OF INJURY JURY AT WORK? .:: 22e. DESCRIBE HOW INJURY OCCURRED ...... ...... .... ..... OYES ONO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 13c. TIME OF DEAT'. 09:00 AM d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) asr n K, I MD 201802508 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE. OF DEATH 5a. AGE - Last Birthday (Yrs.) 84 14a. INFORMANT -NAME Scott H Bilslend 16d. CEMETERY, CREMATORY OR OTHER LOCATION 21a. MANNER OF DEATH El Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ suicide ❑ Could not be determined CITY/TOWN 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? l YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jason K. Hesser, 2910 Betten Drive, Crete, Nebraska, 68333 61s. UNDER 1 YEAR MOS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand 'Island 16b. LICENSE NO. 1200 DAYS STANLEY S. DOOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS OTHER I1 Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH Saline 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Harold Elmer Bilslend 12. MOTHER'S - NAME (First, Middle, Maiden Surname) Marjorie M Argo CITY / TOWN Wood River 9f. ZIP CODE 68801 CAUSE OF DEATH 'See instructions - nd exam • les , its -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, % ular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on it line, Add additional lines if necessary. IMMEDIATE CAUSE: a) Congestive Heart Failure 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Pancreatic Mass 21b. IF IF TRANSPORTATION INJURY u Driver /Operator ❑ Passenger 0 r Pedestrian 0 Other(Specify) STATE Core MINS. 3. DATE OF DEATH (Mo., Day, Yr.) October 9, 2017 6. DATE OF BIRTH (Mo., Day, Yr.) November 15, 1932 1 Year 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ❑ Hospice Facility 24c. P.R QM :,"JNGED DEAD' M? , Ray, +r.. 24d. TINE PRONOI 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(a) stated. (Signature and Title) 9g. INSIOE CITY LIMITS ❑ YES El NO 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) October 13, 2017 STATE Nebraska 17b. Zip .. code 68801 APPROX1MATEINTERVAL onset to death 10 Years onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®wo 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH / ; ; ,. ❑ YES ❑ NO 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR :VA 0. a K z U 26a. HAS ORGAN! OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES ❑ NO