201803768 - Laserfiche WebLink

Browse

'Shad �; \, iii, y 4'k ..;;.o r t cP STATE OF NEBRASKA XiiirroWato N A 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 2018:03768 4/26/2018 LINCOLN, NEBRASKA STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Richard James Kowalski J4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 506 -72 -8036 8b. FACILITY -NAME (If not institution, give street and number) O 217 Arapahoe Avenue ft 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 e lk 9a. RESIDENCE STATE w Nebraska e 9d. STREET AND NUMBER LL a 217 Arapahoe Avenue -i 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married C ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown tv :: 11. FATHER'S.NAME (First, Middle, Last, Suffix) d Donald J Kowalski 9b. COUNTY Hall E I 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. V (Yes, No or Unk.) No sA 1-- 15. METHOD OP DISPOSITION ED Burial ❑ Donation ❑ Cremation ❑ Entombment ❑';Removal ! ❑ Other (Specify) CAUSE OF DEATH. (See instructions and examples) 15. PARTE. Enter the chain Of events- -diseases, injuries, or complications -that directly Caused the death. DO: NOT enter tannlnal events such as cardiac arrest, respiratory arrest er ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Bladder Cancer Metastatic And Myelodysplastic Syndrome disease or condition resulting in death) _ Sepuemia0y list ciinditlons, if any, leading to the -canoe listed on line a. Enter the UNDERLYING CAUSE 040414 0r injufy That initiated 16a. EMBALMER-SIGNATURE Laurie D. Sheffield 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) 5a. AGE - Last Birthday (Yrs.) 65 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 5b. UNDER 1 YEAR MOS, 9c. CITY OR TOWN Grand Island 1 12. MOTHER'S -NAME (First, Betty Jane Verley DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS 9e. APT. NO. 10b. NAME OF SPOUSE (First, Middle, Last, Susan Marie Jaixen MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 Middle, Maiden Surname) 14a. INFORMANT -NAME Susan Marie Kowalski 1Sb. LICENSE NO. 1397 CITY/TOWN Grand Island the:eventsres LAST log death) <:,, DUE TO, OR AS A CONSEQUENCE OF: d) 118. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 1 -, CL W U 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 v(tnin the past year E I a DATE OF INJURY (Mo., Day, Yr.) 0 o a 22d, INJURY Al' WORK? ID [3 YES 0 N 22b. TIME OF INJURY ❑ Suicide 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation Could not be determined „ 1 • U z 23a. DATE Of DEATH (Mo., Day, Yr.) A32ri) 19, 2018 3b....01 SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH April 23, 2018 09:10 PM • a 0 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) Ryan Ramaekers, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES ® NO ❑ PROBABLY ❑ UNKNOWN 28a.REGISTRAR'SSIGNATURE/ � I 21b. IF TRANSPORTATION 0 Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) INJURY 24a 6 TE SIGNED (Mo., Day, Yr.) 24c, PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 7 NO 3. DATE OF DEATH (Mo., Day, Yr.) April 19, 2018 Suffix) If wife, give maiden name 6. DATE OF BIRTH (Mo., Day. Yr.) February 28, . 953< 3 Years ❑ Hospice Facility 9 INSIDE CITYLIM(TS: ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Me., Day, Yr.) April 23, 2018 STATE Nebraska 1 ?b, Zip Code 68801 onset to death onset to death APPROXIMATE 19. WAS MEDICAL EXAMINER OR CORONER. CONTACTED? _... ❑ YES ®NO' 21c. WAS AN AUTOPSY PERFORM ❑ 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 1 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED BEAD 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 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan Ramaekers, MD, 2116 W. Faidley Avenue, Grand island, Nebraska, =8803 28b. DATE FILED BY REGISTRAR (MO., Day, Yr. April 23, 2018