|
,.V:;Aiiii
<br />Lu
<br />at
<br />re
<br />Lu
<br />• WHEN THIS. COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />201805110
<br />2/14/2017
<br />LINCOLN; NEBI?ASKA
<br />1. DECEDENTS-NAME (First, Middle, Last, Suffix)
<br />Wesley Lavern Brooks
<br />4::crry•Nc$TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Clarks, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-32-9112
<br />Sb FACIL1TY-NAME (If not Institution, give street and number)
<br />CH1 Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />ea, RESIDENCE-STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />3019 West 15th Street
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH @ Married 0 Never Married
<br />1:1 Married, tart separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S-NAME (F(rst, Middle, Last, Suffix)
<br />James Brooks
<br />• 13. EVER IN U.S.ARMED:FORCES? Give dates of service if Yes.
<br />g ( yoi; No, or POO No
<br />2. 15. METHOD OF:DISPOSITION • E Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />.0 Removal •• 0 Other (Specify)
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d..:INJURY DYES ONO
<br />• "
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 5, 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />2 -1 February 8, 2017
<br />7 1, o
<br />2 g
<br />g
<br />reiraellt Antisaik.a, Autalit u'4169,1%,
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />16a. EMBALMER-SIGNATURE
<br />Katie M. Smydra
<br />20. If
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />!•: Not:pregnarit„pot pregnant within 42 days of death
<br />• Not pregeatit.titit pregnante3 days to 1 year before death • • launimewn ifiresnenr Wilkie the past year
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />T:w5..cr I
<br />08:55 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />5a. AGE - Last Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />81
<br />8a. PLACE OF DEATH
<br />HOSPITAL 1g] Inpatient
<br />0 ER/Outpatient
<br />E] DOA
<br />Delores Jean Knuth
<br />14a. INFORMANT-NAME
<br />Delores Jean Brooks
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />CITY/TOWN
<br />25. DID TDEACOQIJSE CONTRIBUTE TO THE DEATH?
<br />@ YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg MD 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />- avevia."4-
<br />28a. REGISTRAR'S SIGNATURE A
<br />16b. LICENSE NO.
<br />1454
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Mildred Peck
<br />CAUSE OF D H ee instructions and exam es
<br />tri, PART I. Enter the chain ef ti s. -diseases, injuries, or complications-that directly caused the death, DO NOT enter temlinal events such as cardiac arrest,
<br />respiratory atteet, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only One cause WI a see. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />In de414) DUE TO OR AS A CONSEQUENCE OF
<br />Sequentially list conditions, if b) Pneumonia
<br />any, leading to the Cause hated
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C) Aspiration
<br />(disease Of injury that initiated
<br />the enema resumes in death) DUE TO OR AS A CONSEQUENCE OF
<br />• LAST ..
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Parkinsons
<br />21c. WAS AN AUTOPS107iFoRmEr:::.
<br />• YES @ NO •
<br />Accident 0 Pending Investigation
<br />21b, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />0 Suicide 0 Could OM be determined
<br />0 Oth (Specify) TO COMPLETE CAUSE OF DEATH?
<br />• er
<br />• YES NO
<br />22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />STATE
<br />26a. HAS OR=AN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES 'ZINO
<br />MINS.
<br />February 8, 2017
<br />p .
<br />ASV"'
<br />7ft
<br />1••
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 5, 2017
<br />6. DATE OF BIRTH (Mo, Day, Yr.)
<br />August 27, 1535
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife •
<br />16c. DATE (Mo., Day.Yr.}
<br />February 9, 2017
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />p YES 13 NO
<br />STATE
<br />Nebraska
<br />17b, Zip Code
<br />68801 •
<br />APPROXIMATEINTERVAL
<br />onset to death •. •
<br />4 Days
<br />onset to death
<br />7 Days
<br />onset to death
<br />7 Days
<br />onset IA) death
<br />24e. On the basis of examination and/or investiga ion, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES El NO
<br />ZIP CODE
<br />• 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />S
<br />Ti C' 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<br />g
<br />u4 .
<br />8
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO D YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (M, Day, Yr.): •
<br />••••
<br />
|