201900975 - Laserfiche WebLink

Browse

i.my3 ,a,� (ll�d # ; I r4 }i ! . i{ I d aF tis f 6111),‹ STATE OF NEBRASKA „t 14 Nl <E o 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 6/14/2018 LINCOLN, NEBRASKA 201900975 STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 18 07344 To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ronald Leo Harders 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) May 28, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 513. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 60 MOS. DAYS HOURS MINS. August 31, 1957 7. SOCIAL SECURITY NUMBER 506-84-0782 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) 1421 Lilley Street 0 ER/Outpatient E Decedent's Home 0 DOA 0 Other (Specify) i6c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Wood River 9d. STREET AND NUMBER 1421 Lilley Street 9e. APT. NO. 9f. ZIP CODE 68883 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL 0 Married, STATUS AT TIME OF DEATH E Married 0 Never Married but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Mary A Preuss 11. FATHER'S -NAME (First, Middle, Last, Suffix) Lyle Harders 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Frances Runge ,3. EVER IN U.S. ARMED, FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Mary A Harders 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION E Burial ❑ Donation 16a. EMBALMER -SIGNATURE Gwen K. Hyronemus 18b. LICENSE NO. 1448 16c. DATE (Mo., Day, Yr) June 2, 2018 ❑ Cremation 0 Entombment ❑ Removal '❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Berwick Cemetery Cairo Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) : ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska 17b.Zip Code 68801 CAUSE OF DEATH (See instructions and examples) �_ To be completed by: CERT1FRER 18. PART 1. 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 respiratory arrest, orventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only onecause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Sudden Cardiac Arrest disease or condition resulting onset to death Immediate in deathl DUE TO, OR AS A CONSEQUENCE OF: Seauentiatlylist conditions, if b)Arrythmia any,leading to the Cause listed onset to death Seconds on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C, (disease or injury, that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Alcoho( Use, Tobacco Use 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH E Natural 0 Homicide 0 Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ENO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnam 43 days to 1 year before death 0 Unknown K pregnant within the past year ❑ourm 0 Suicide Could not be determined ❑ Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? z ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE mpleted by -.. CERTnER NLY 23a. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONER'S PHYSICIAN or CC UNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) June 6, 2018 24b. TIME OF DEATH Unknown 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) May 28, 2018 24d. TIME PRONOUNCED DEAD 03:30 PM 123d. To the best of my knowledge, death occurred at the time, date and place I anc..;u0 0J u:e ccu ei , stared. (C. nu,,::c and TiVr) 24e. On the basis of examination and/or investigation, in my opinion death occurred at 11• e, da;c n',d pica and due to tra can s7s) state a. ;Signature and Thiel Katherine J. Doering, Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO E PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES fiCI NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Katherine J. Doering, Deputy County Attorney, 231 South Locust, Grand Island, Nebraska, 68801 28a. REGISTRAR'S SIGNATURE S. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 8, 2018 Exhibit "A"