201807502 - Laserfiche WebLink

Browse

STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANO.HUMAN'SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGIIVAI-41gWen Off gE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, ,WhyCH IS • THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAY 2 7 2008 LINCOLN, NEBRASKA 201807502 TANLEY S. COOPER ASSISTANT STATE REGISTRAR - HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FIPIANCEANO SUPPORT - CERTIFICATE OF DEATH - 06 30205 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Hu•o George Wiese 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) September 13, 2006 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Hall County, NEbraska (Yrs.) 87 MOS. DAYS HOURS MINS. February 22, 1919 7. SOCIAL SECURITY NUMBER 506-20-2727 8a. PLACE OF DEATH HOSPITAL.: ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility Bb. FACILITY -NAME (If not institution, give street and number) ti St. Francis E.R. LER/Outpatient ❑ Decedent's Home ❑ 004 U Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1916 West 10th 9e. APT. NO 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS git YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH a Married ❑Never Married ❑ Married, but separated U Widowed U Divorced ❑ Unknown tOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name. Susan L. Lampitelli I ^t 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred C. Wiese 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anna Dorothy Reher %'. 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, orunk.)YES 7/31/44-2/19/46 14a. INFORMANT -NAME Susan Wiese 14b. RELATIONSHIP TO DECEDENT Wife r.Nt 15. METHOD OF DISPOSITION ,Burial ❑Donation 16a. E ALMER-SIGNATURE R. 16b. LICENSE NO. 1143 16c. DATE (Mo., Day, Yr. ) ►eptember 16, 2006 t � ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Cemetery, Grand Island, NEbraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code Livingston -Sondermann Funeral Home 601 N. Webb Rd., Grand Island, NE 68803 �su�-? �s x v. n �: i . .... �.... ... ��d l ... .<. i w �, w 1 ( t�Y .::Y-'. ..✓ s.n" . . ?FsSa,x) -.. 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, APPROXIMATE INTERVAL �3 ?� respiratory arrest, or ventricular fibrillation without showingthe etiology. DO NOT ABBREVIATE. Enter onlyone cause on a line. Add additional lines if necessary. P Y 9R i IMMEDIATE CAUSE: I Xet to death ( (a) cardiopulmonary arrest 115 minutes IMMEDIATE CAUSE Final P Y y c q> disease or conditionresufting DUE TO, OR AS A CONSEQUENCE OF: i onset to death in death) Sequentially list conditions, It (b) vertebral fracture and hematoma 5 minutes �.. ra any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onset to death on line,. Enter the UNDERLYING CAUSE (disease or injury that Initiated (C) fall none IASf� resulting In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death (d) 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 1 A MEDICAL EXAMINER OR CORONER CONTACTED? a YES ❑ NO -, 3w' 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death t. MANNER OF DEATH / ❑Natural ❑Homicide M Accident LI Pending Investigation 21b. IF TRANSPORTATION INJURY ❑Driver/Operator ❑Passenger yE. WAS AN AUTOPSY PERFORMED? / ❑ YES a NO ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year ❑ Suicide ❑ Could not be determined U Pedestrian U Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? U YES tC1 NO w 22a. DATE OF INJURY (Mo., Day, Yr.) Sept. 13, 2006 22b. TIME OF INJURY 11:00 22c. PLACE OF INJURY -At home, farm, P m Home street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES $ NO 22e. DESCRIBE HOW INJURY OCCURRED Fall stairs 22f. LOCATION OF INJURY- STREET& NUMBER, APT. NO. CfTY/TOWN STATE ZIP CODE 1926 West 10th, Grand Island, NE 68801 To be completed by Attending PHYSICIAN ONLY 23a. DATE OF DEATH (Mo., Day, Yr.)Z September 13, 2006 y a0 cc DATE SIGNED Mo., Day, Yr.) /18/2b06 TIME OF DEATH 12:03 am } " DATE SIGNED (Mo., Day, Yr.) 23c DAMOF DEATH m cp z = 0 aaa, Epz PRONOUNCEDDEAD ( o., Day, Yr.) 9/13/2006 2 TI E P 0 OUNCED DEAD :� am To the best of my knowledge, death occur ed at the time, date and place and due to the cause(s) staled. (Signature and Title) °u w z o o ~ 8.6 2 On the basis of examination and/or investigation, in my opinion death occurred at 7 the time, date and place nd due to the cause(s) stated. (Signature and Title ) • A. DID TOBACCO USE CONTRIBUTETO THE DEATH? ❑ YES X NO ❑ PROBABLY ❑ UNKNOWN 2)'HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 2 NO 76".W SENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO �AME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Mark Young, Hall County Attorney: 231 S. Locust, Grand Island NE 68802 , ► ► 1,,' 2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.) SEP 2 0 2006 v r