201803806 - Laserfiche WebLink

Browse

STATE OF NEBRASKA einattsk, YX ;C2 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 3/26/2018 LINCOLN NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Janet Marlene Carman 4. CITY': AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Pleasanton, Nebraska 7. SOCIAL SECURITY NUMBER 50 -7430 Sb. FACILITY- NAME(I1not;ltt give street and number) Mother Hull Home` 8c, CITY OR TOWN OF DEATH (Include Zip Code) Kearney 68847 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 202 N Pine aTsi 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑',Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown m STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 9b. COUNTY Buffalo 11. FATHER'S -NAME (First, Middle, Last, Suffix) Earl Eaton 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) NO 15. METHOD OF DISPOSITION ® Burial "❑ Donation ❑ Cremation ❑ Entombment [3 Removal 0 Other (Specify) 16a. EMBALMER- SIGNATURE Mark McBride Pleasanton Cemetery 201 � STANLEY COOPER V 8` 3 8 0 6 ASSISTA L STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH a. AGE - Last Birthday (Yrs.) 84 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ERfOutpatient ❑ DOA 14a. INFORMANT -NAME Darold Carman 9c. CITY OR TOWN Pleasanton 5b. UNDER 1 YEAR MOS. DAYS 9e. APT. NO. 2. SEX Female HOURS 1 8d. COUNTY OF DEATH Buffalo lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Darold Carman 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Sophia Kreitzer i 6b. LICENSE NO. 1199 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Pleasanton 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Horner Lieske McBride & Kuhl Funeral and Cremation. 2421 Avenue A, Box 777. Kearney. Nebraska 8. 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 line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Metabolic Encephalopathy IMMEDIATE CAUSE (Final disease or condition resulting in death) SegcfOntially list conditions, if any, leading to the Cause listed on tide a:' - Enter the UNDERLYING CAUSE disease or injury tltat mdfeted the ev resyamg in death) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. IF:FEMALE: ❑ Not pregnant withimpast year ❑ Pregnant at time of death ❑ Nat pregnant, butpregnant within 42 days of death ❑ Not pre b ut pre gnant 43 days to 1 year before death •Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d..I AT WORK? ❑YES ONO 13a,,DATE (Mo., Day, Yr.) • Maroh 11 2018 DUE TO, OR AS A CONSEQUENCE OF: b)Oropharyngeal Dysphagia DUE TO, OR AS A CONSEQUENCE OF: c)Alzheimers Dementia DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED . LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH € u March 16, 2018 07:04 AM q O 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) states, (Signature and Title) 2 Robert C. Messbarger, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 0 NO ❑ PROBABLY ❑ UNKNOWN 28a. REGISTRAR'S SIGNATURE CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ CoNd not be determined CITY /TOWN 26a. HAS ORGAN OR TISSUE DONA ® YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Robert C. Messbarger, MD, 3907 6th Avenue, Kearney, Nebraska, 68845 24a. DATE SIGNED (Mo., Day, Yr.) ON BEEN CONSIDERED? Exhibit "A" 5c. UNDER 1 DAY STATE MINS. OTHER 0 Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68866 1b, IFTRANSPORTATION INJURY Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) January 19, 1934 16c. DATE (Mo„ Day, Yr.) March 16, 2018 onset to death 4 Weeks onset to deattl 6 Months onset to death 5 -10 Years 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH STATE Nebraska 17h, Zip Code 68848 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date - and place: end. due to the rauaela) stated. (Signature and Title) 3. DATE OF DEATH (Mo., Day, Yr.) March 11, 2018 6. DATE OF BIRTH (Mo Day, Yr.), ❑ Hospice Facility 9g. INSIDE CITY LTMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT_. Spouse APPROXIMATE INTERVAL 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? Ea YES ❑ NO' 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ Nfl 24d. TIME PRONOUNCED DEAD ZIP CODE 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 28b. DATE FILED BY REGISTRAR (Mo, Day, Yr,) March 16, 2018