201900990 - Laserfiche WebLink

Browse

attamilioi4(ert STATE OF NEBRASKA 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 12/17/2018 LINCOLN, NEBRASKA 2RUSSELL FOSLE 019 0 0 9 0 0 ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH • Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filer) with the county court in the county where the decedent resided at the time of death. I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ruth Marie Hunt 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) December 4, 2018 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.) Grand Island, Nebraska (Yrs.) 72 MOS. DAYS HOURS MINS. February 20, 1946 7. SOCIAL SECURITY NUMBER 506-58-7815 Ba. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) N. Engieman Rd ❑ ER/Outpatient ® Decedent's Home 0 DOA 0 Other (Specify) 2115 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hat 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN. Grand island 9d. STREET AND NUMBER 2115 N. Engleman Rd 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ril YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH IE Married ❑ Never Married ❑ Married, but separated 0 Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Roy Lee Hunt 11. FATHER'S -NAME (First, Middle, Last, Suffix) Herbert J Harder 12 MOTHER'S -NAME (First, Middle, Maiden Surname) Ella F Suehlsen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Una.) No 14a. INFORMANT -NAME Roy Lee Hunt 14b. RELATIONSHIP TO DECEDENT. Spouse 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Stacie L Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) December 10, 2018 0 Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 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 respuratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on aline.: Add additional lines if necessary. ,MMEDiATL CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting onaot tc deeth < 1 Week in death! DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, ,f b)Metastatic Ovarian Cancer any, leading to the cause listed onset to death > 1 Year 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: . onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Coronary Artery Disease. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 20. IF FEMALE: 0 Not pregnant within past year Pregnant at time o1 death 21a. MANNER OF DEATH ® Natural 0 Homicide 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? !' 0 YES ®NO ❑ 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days 801 year before death Unknown if within the past year Accident ❑ Pending Investigation 0 Suicide 0 Could not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO pregnant 0 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? m ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) December 4, 2018 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY'. ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 7, 2018 23c. TIME OF DEATH 07:58 AM 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jennifer L. Brown, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO 0 PROBABLY ® UNKNOWN r26a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED? 0 YES 7 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) Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska 68803`' 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) s. December 12, 2018 •."-- WE HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT COPY FIVE PO,I T, B a ,I K Pwor