|
j'iN.. 9gfla�t �q.:A+h34E.xaalc�aanag�ea{`,s-xaca'� t6Gy9'r�s+a�'3Y, �@pp�
<br />v{ifihiraw�i A&33i�5kb Ii [aafltAR� B.NN'45275��id`'N/a sl9e Viintbk .. `atg eFa
<br />VIDA
<br />4 aslaaa►as § 2y111I111i1Ii)a .N �asx�ViNWASe t2d1 i
<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 />s
<br />DATE OF ISSUANCE
<br />LINCdL3, N1gRASKA
<br />Amended
<br />RUSSELL FOSLER
<br />INTERIM ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent residedat the time of death. I.
<br />1. DECEDENTS NAME (First, Middle, Last, Suffix)
<br />Bernard Eugene Horst
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 21, 2018
<br />d. CITU AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />69
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 2, 1949
<br />7. SOCIAL SECURITY NUMBER
<br />,,.506-72.8781
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER El Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />CHI Health St. Francis
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA ❑ Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1726 Lariat Lane
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />1oa. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Margene Kuhlmann
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Merle E Horst
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Imogene Stelk
<br />33. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk,) No
<br />14a. INFORMANT -NAME
<br />1 Margene Horst
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCov
<br />16b. LICENSE NO.
<br />1191
<br />16c. DATE (Mo., Day,Yr.)
<br />September 26, 2018
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />1713, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the'.Chain of everts --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventrrGUlar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Recurrent Aspiration Pneumonia
<br />disease or condition resulting
<br />onset to death
<br />1 Year
<br />3n death)
<br />Sequentially
<br />any, leading
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />list conditions, if ,; b)Invasive Squamous Cell Carcinoma Oropharynx
<br />to the cause fisted"
<br />onset to death --
<br />3 Years
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the. UNDERLYING CAUSE c)
<br />{disease or injury that initiated'-
<br />onset to death
<br />the events resulting in Death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Type 2 Diabetes, Coronary Artery Disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YES ®NO
<br />20. IF FEMALE: :.
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH `
<br />® Natural 0 Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Nat pregnant, but pregnant 43 days tot year before death
<br />0 Unknown if pregnant within the past year
<br />❑ 0
<br />Cou
<br />❑ Suicide Could not be detemtmed
<br />❑
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK? ''
<br />❑ VES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September'21, 2018
<br />z >
<br />a
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 21, 2018
<br />23c, TIME OF DEATH
<br />02:10 AM
<br />3 F, o
<br />E a. z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and. due to the causes) stated. (Signature and Title)
<br />Ryan D. Crouch, DO
<br />' w z
<br />2 z
<br />~ o a
<br />u
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is N0 ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand
<br />Island, Nebraska, 68803
<br />28a, REGISTRAR'S SIGNATURE
<br />-- L* '' -
<br />dA:�
<br />28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.)
<br />September 25, 2018
<br />Amended
<br />10/4/2018 Items 1, 11, 14a Corrected Surname Host To Horst
<br />10/16(2018 Item 8a From Inpatient Hospital To Nursing Home, Item 8b CHI Health St. Francis, Hospital To CHI Health St. Francis Skilled Care
<br />
|