|
STATE OF NEBRASKA
<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 />9/19/2017
<br />LINCOLN, NEBRASKA
<br />20190085g
<br />avow
<br />STANLEY S. VOOPER
<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 />17 11554
<br />ITo be completed/verified by: FUNERAL DIRECTOR
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Audrey Elaine Dcminick
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 10, 2017
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />513. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Ireton, Iowa
<br />(Yrs.)
<br />76
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />July 21, 1941
<br />7. SOCIAL SECURITY NUMBER
<br />483-50-3819
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />824 S. Cher??
<br />0 ER/Outpatient El Decedent's Home
<br />0 DOA 0 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 />824 S. Cherry
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />El YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 2 Married El Never Married
<br />0 Married, but separated CI Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Eugene Dominick
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Leon De Raad
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Freda Ramherst
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or unio No
<br />14a. INFORMANT -NAME
<br />Eugene Dominick
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />September 13, 2017
<br />0 Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />To be completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />id PART I. Enter the chain cif events- -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 ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Peripheral T -Cell Lymphoma
<br />disease or condition resulting
<br />onset to death
<br />3 Years 10 Months
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list contusions, it b)
<br />any, leading to the Cause listed
<br />onset to death
<br />on line C.
<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 />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES lia NQ
<br />20. IF FEMALE:
<br />0 Not pregnant Within past year
<br />EI Pregnant at time of death0
<br />21a. MANNER OF DEATH
<br />El Natural 0 Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES [2] NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />El 0
<br />El Suicide 0 Could not be determined
<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 ATINORIO
<br />DYES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 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 />Sebternter 10. 2017
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 11, 2017
<br />23c. TIME OF DEATH
<br />07:45 PM
<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 cause(s) stated. (Signature and Title)
<br />Nick Hartl, MD
<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 />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES El NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED?
<br />DYES 0 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Nick Hartl, MD, 412 W. 42nd Street, Kearney, Nebraska,
<br />68845
<br />,
<br />28a. REGISTRAR'S SIGNATURE A caotp„,„,
<br />..
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 13, 2017 I
<br />
|