201803751 - 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 201803751 ' As STANLEY S STATE REGISTRAR 4/30/2018 DEPARTMENT HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH v, ^ l.d T:v it d../' I I:, O. E 0 U . m :: r- 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Iva Belle Lowry 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Friend, Nebraska 7. SOCIAL SECURITY NUMBER 508-12-0651 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE lira. COUNTY Nebraska Hall 9d. STREET AND NUMBER 14576 W. White Cloud Road 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑Married, but separated ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (first, Middle, Last, Suffix) Joseph Robert Zaiic 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Bessie Ellen Blunt 13. EVER IN U.S,:ARMED:FORCES? Give dates of service if Yes. (Yes, NO, or link.) No 15. METHOD OFDISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Ctlter (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home. 1123 W. 2nd. Grand Island, Nebraska CAUSE OF DEATH, (See instructions and examples) 18. PART I. Enter the chain of 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 tine. Add additional lines if necessary. IMMEDIATE CAUSE: a)Acute Respiratory Failure IMMEDIATE CAUSE (Final disease or condition resulting APPROXIMATE INTERVAL onset to death 15 Mins in death) Setjuentlally list contlitlons, # any,,ieading to theiause listed on lino a. Enter the UNDERLYING CAUSE (disease of injury:: that initiated the events fesuking in death) DUE TO, OR AS A CONSEQUENCE OF: b) Bilateral Pulmonary Embolism, Pneumonia !' DUE TO, OR AS A CONSEQUENCE OF: c) onset to death LAST DUE TO, OR AS A CONSEQUENCE OF: d) onsettO death 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Encephalopathy, ACute On Chronic Kidney Failure, Unknown Primary Cancer, Small Bowel Obstruction i; 20. IF FEMALE: I, ❑ Not pregnant within past year U ❑ Pregnant at time of death ❑Net pregnant, but pregnant within 42 days of death A ❑ Not pregnant; but pregnant 43 days to 1 year before death ❑ Unknown if piegnarit within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d INJURY AT::WORK? ❑YES ] NO 23a. DATE OF DEATH (Mo., Day, Yr.) April 25, 2018 1 28a, REGISTRAR'S SIGNATURE 16a. EMBALMER - SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 22b. TIME OF INJURY a I i" 23b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH I i z April 26, 2018 04:55 PM q 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 and due to the cause(s) stated. (Signature and Title) • Ma C herukula, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN Sa, AGE - Last Birthday (Yrs.) 95 14a. INFORMANT -NAME Mike Lowry 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide Could not be determined J - Der 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Cairo 21b. (F TRANSPORTATION INJURY Driver /Operator ❑ Passenger Pedestrian Other (Specify) DAYS 9e. APT, NO. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Madhavi Cherukula, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 8d. COUNTY OF DEATH Hall 16b. LICENSE NO. 24a. DATE SIGNED (Mo., Day, Yr.) 24c, PRONOUNCED DEAD (Mo., Day, Yr.) 9f. ZIP CODE 68824 3. DATE OF DEATH (Mo., Day, Yr.) April 25, 2018 November 2 6. DATE OF BIRTH (Mo., Day, Yr, 3, 1922 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9g. INSIDE CITY LIMITS ❑ YES El NO lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Robert White Lowry 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (MO„ pay, Yr.) April 27, 2018 17b, Zip Cade 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES. NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑; NO 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 & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 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 cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR April 30, 2018 o., Day, Yr.) i