201804969 - Laserfiche WebLink

Browse

STATE OF NEBRASKA 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 4/23/2018 LINCOLN, NEBRASKA 201804969 STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH r 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Faye Lorraine Wagner 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Holyoke, Colorado 7. SOCIAL SECURITY NUMBER 507 -72 -8934 8b. FACILITY - NAME (tf not Institution, give street and number) 819 S. Stuhr Road 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a. RESIDENCE - STATE Nebraska 9d. STREET AND NUMBER 819 S. Stuhr Road 1Oa. MARITAL STATUS AT. TIME OF DEATH E Married ❑ Never Married © but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Vernon Gerald Kumm 13. EVER IN U.S.ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION ❑ Burial a Donation E Cremation ❑ Entombment ❑ Removal '0 other (Specify) 20. IF; FEMALE: Not pregnant whhin past year ❑ Pregnant at time of death ❑ Nut pregnant, but pregnant within 42 days of death © Not pregnant, put pregnant 43 days to 1 year before death ❑ Unknown it pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) A 22d, INJURY ATINORK? d 12 ❑ YES ❑ NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. Travis S, t-tageman, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE .• Last Birthday (Yrs.) 65 9b. COUNTY Hall MOS. 14a. INFORMANT- NAME Mikel Dennis Wagner 16a. EMBALMER- SIGNATURE Not Embalmed 5b. UNDER 1 YEAR DAYS HOURS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC E Decedent's Home ❑ Other (Specify) Hospice Facility 9c. CITY OR TOWN Grand! Island 9e. APT. NO. 10b. NAME OF SPOUSE (First,: Middle, Last, Suffix) If wife, give maiden name Mikel Dennis Wagner 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Berneice Helen Rafert 16b. LICENSE NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska CAUSE OF DEATH {See; instructions and examples) a. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter temunal events such as cardiac arrest, respiratory crest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause " on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE Tina! a) Metastatic Breast Cancer disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: Setwentiahy listeo{fd woos , d b) any, teadin9 to the cause listed on lines • Enter the UNDERLYING CAUSE (disease dr injury .thet iehiated DUE TO, OR AS A CONSEQUENCE OF: c) onset to death the events resultng m deethj LAST: DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulti ng in the underlying cause given in PART I. 22b. TIME OF INJURY CITY/TOWN 23a. DATE OF ,DEATH (Mc., Day, Yr.) November 4'7, 2017 23b. DATE S(GNED (Mo., Day, Yr.) November 18, 2017 23c. TIME OF DEATH 08 :44 AM 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED Q W J C t U Z a O 3d. To the best of my knowledge, death occurred at the time, date and place 2 I-2 and due to the cause(s) stated. (Signature and Title) 0 r W 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ could not be determined 1 28a. REGISTRAR'S $#GNATURE j 07 . 6 ..„, 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 26a. HAS ORGAN OR TISSUE:: DONATION BEEN CONSIDERED? ❑ YES E NO 2. SEX Female 5c. UNDER 1 DAY MINS. 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68801 3. DATE OF DEATH (Mo., Day, Yr.) November 17, 2017 6. DATE OF BIRTH (MO:, Day, vv.) May 14, 1952 9g. INSIDE CITY LIMITS El YES ❑ NO 14b. RELATIONSHIP TO DECEDEN:T'<: Spouse 16c. DATE (Mo., Day, Yr) November 20, 2017 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES; ENO::: 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO STATE ZIP CODE 2Aa DATE:Sir:NFD (Mo., Day Yr) 2db. TIME OF DFAYiI 24c. PRONOUNCED DEAD (Mo., Day, Yr. 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 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hagema,n, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (MO„ Day, Yr.) November 20, 2017