201805338 - 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 2/12/2018 LINCOLN, NEBRASKA J Q y Nebraska I Hall I9d. STREET AND NUMBER a 4151 Sprinqview Drive ; gl 9a. RESIDENCE. -STATE 19b. COUNTY g r a .. �, . �. m ' V r Y 1 ,. ti,R L �x..1� ,.rr l,A ,..bd , 201805338 9c. CITY OR TOWN Grand island - STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH tK C3 W 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Roy Donald Cadwalader 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup City, Nebraska 7. SOCIAL SECURITY NUMBER 508 -1.8 -8863 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 5a. AGE - Last Birthday (Yrs.) 90 517. UNDER 1 YEAR MOS. DAYS 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) February 6, 2018 6. DATE OF BIRTH (MO., Day, Yr.) March 29, 1927 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 0 Hospice Facility 8d. COUNTY OF DEATH Hall d 81 0. E 8 1 2 I- 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married © Married, but separated E Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Walter Cadwalader 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Daisy Fletcher 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) Yes 04/11/1944- 05/23/1946 15. METHOD OF DISPOSITION Burial 0 Donation O Cremation ❑ Entombment ❑ Removal ❑ Other (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 line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Pancytopenia /Anemia disease or condition resulting in death) APPROXIMATE INTERVAL onset to death 5 Years sequentially list conditions, I arty, leading to the Cause hated on line a DUE TO, OR AS A CONSEQUENCE OF: b) Waldenstroms Macroglobulinemia '< onsettq death 5 Years DUE TO, OR AS A CONSEQUENCE OF: C) onset to death Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not resulting in the underlying cause given in PART I. Renal Failure;: Chronic Obstructive Lung Disease y„ 20. IFFEMALE: 0 Not pregnant within p year WU ❑ Pregnant at time of death n egne `41 -, „ re sn' ..: x2 .z.. :.I 4.,!01 . + 1 Unkno i pregnant Witti the past year before death CI, E t, 17 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? DYES 0 Nb 22f, LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) February 6 2018 b, DATE SIGNED (Mo., Day, Yr.) February 8, 2018 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 D. Crouch, DO 22b. TIME OF INJURY 1017. NAME OF, SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Mary Wanitschke 14a. INFORMANT -NAME Janet Griffin 16a. EMBALMER - SIGNATURE Gwen K. Hvronemus 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Memorial Park Cemetery Grand Island STATE Nebraska 21a. MANNER OF DEATH E Natural 0 Homicide ❑ Accident ❑ Pending Investigation U Suicid a{i e ❑ Coti,ut Ae ueter'.ni[ 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 03:57 PM 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Be. I APT. NO. 19f. ZIP CODE f 1 68803 16b. LICENSE NO. 1448 21b. IF 'TRANSPORTATION INJURY '❑ Driver /Operator ❑ Passenger f1 pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. ONOUNCED DEAD (Mo., Day, Yr.) 25 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? YES NO PROBABLY UNKNOWN ❑ YES E NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 285. REGISTRAR'S SIGNATURE 1 3 - /fi,._, ' 9g. INSIDE CITY LIMITS YES E NO 14b. RELATIONSHIP. TO DECEDENT :. Daughter 16c. DATE (MO., Day, Yr) February 10, 2018 17b.Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? - ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE it) I:V as r LcTE CAUGi OF DEEATH? ❑ YES ❑ NO 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) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yt,) February 8, 2018