201804528 - Laserfiche WebLink

Browse

. `�4 ta• 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 8 DATE OF ISSUANCE 6/25/2018 LINCOLN, NEBRASKA STATE OF NEBRASKA uam miry -.' st` RUSSELL FOSLER DEPARTMENT HEALTH AND INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE! OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Mary Kay Qualsett 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Albion, Nebraska 7. SOCIAL SECURITY NUMBER 505 -50 -6872 8b. FACILITY -NAME (If not Institution, give street and number) 1914 Stolley Park Circle 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. REStDENCESTATE Nebraska 9d. STREET AND NUMBER 1914 Stolley Park Circle 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN US. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Usk.) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation Cremation ❑ Entombment ❑ Removal '; ❑ Other (Specify) Enter the UNDERLYING CAUSE (dinned:0 r injury that(niaailad the events resulting in death) LAST 20 IF FEMALE ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Net pregnant, but pregnant within 42 days of death 0 Not pregnant; but pregnatlt 43 days to 1 year before death 0 Unknown If pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d, (.. NJURY AT WORK? ❑YES ❑ NO 23a flATE •OF DEATH (Mo., Day, Yr.) ,dune 15, 2D18 tl 1 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 10 NO ❑ PROBABLY ❑ UNKNOWN 28a. REGISTRAR'S SIGNATURE 5a. AGE - Last Birthday {Yrs.) 76 9b. COUNTY Hall MOS. 16a. EMBALMER- SIGNATURE Not Embalmed 22b. TIME OF INJURY 23b. PATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH June 19, 2018 10:40 PM C 0 a O 3d. To the best of my knowledge, death occurred at the time, date and place m 2 o and due to the cause(s) stated. (Signature and Title) E ~ 2 Brian K. Buhlke, DO 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 26a. HAS ORGA ❑ YES 5b. UNDER 1 YEAR DAYS 9e. APT. NO. N OR TISSUE DONATION BEEN CONSIDERED? El NO 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) June 15, 2018 March 22, 1942 6. DATE OF BIRTH (MO., Day, 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC El Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9f. ZIP CODE 68803 14a. INFORMANT -NAME Orville Qualsett 16b. LICENSE NO. 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 216. IF TRANSPORTATION 0 Driver/Operator ❑ Passenger 0 Pedestrian Other (Specify) INJURY 24a. DATE SIGNED (Mo., Day, Yr.) 24C. PRONOUNCED DEAD (Mo., Day, Yr.) 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (first, Middle, Last, Suffix) If wife, give maiden name Orville Qualsett 11. FATHER'S -NAME (First, Middle, Last, Suffix) Kermit Mortensen 12. MOTHER'S -NAME (First, Myrtle Peterson Middle, Maiden Surname) 14b. RELATIONSHIP TO DECEDENT Husband! 16c. DATE (Mo., Day, Th) June 19, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 17b, Zip Code 68801 CAUSE OF DEATH (See instructions and examples) . . . _ rth or e 18. PART Ente 1. r t(rg chain of Byents- •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 (Final disease or condition resulting IMMEDIATE CAUSE: a) Mycobacterium Avium Complex APPROXIMATE INTERVAL onset to death > 1 Year in death) Sequentially list conddfens, N any, leading to the cause bided on line . a _.._ DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES :I ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF;DEATH? ❑ YES ❑I NQ 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 ▪ o. 6 w 24e On the basis of examination and /or investigation, in my opinion death occurred at ▪ K p the time, date and place and due to the cause(s) stated. (Signature and Title) 8° 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ N 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Brian K. I3uhlke,DO, 2510 18th Avenue, Central City, Nebraska, 68826 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 21, 2018