201902765 - Laserfiche WebLink

Browse

.� rra�y;;i,, ,,xx��yy}}�� +� �g 3 i9 1J;i<Li'�5 %)St' re x't' 44; le ... I' • 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 RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DATE OF ISSUANCE 5/3/2019 201902765 LINCOLN, NEBRASKA 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 resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Keith Arden Fischer 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) April 15, 2019 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.) Geddes, South Dakota (Yrs.) 76 MOS. DAYS HOURS MINS. October 8, 1942 7. SOCIAL SECURITY NUMBER 503-46-8498 Ba. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (Knot Institution, give street and number) Mary Lanninq Healthcare 0 ER/Outpatient ❑ Decedent's Home 0 DOA 0 OrhertSpecify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Hastings 68901 8d. COUNTY OF DEATH Adams 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 409 Takewood Cr. 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married 0 Married, but separated, 0 Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Jane Nolan 11. FATHER'S -NAME (First, Middle, Last, Suffix) Wilbert Fischer 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Alyce Hyde 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Jane Fischer 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) April 17, 2019 ® Cremation 0 Entombment 0 Removal ; 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Westlawn Memorial Park Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livinaston-Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska 17b. Zip Code 68803 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 respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a)Adult Failure To Thrive disease or condition resulting -~ onset to death Weeks in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if -. b)Advanced Alzheimer's Type Dementia any, leading to the cause listed onset to death:, Years 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. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES E NO. 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 21a. MANNER OF DEATH E Natural ❑ Homicide Accident Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ENO ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year ❑Pending 0 ❑Suicide ❑Could not be determined ❑ Pedestrian 0 Other (Specify) 21 d. WERE AUTOPSY FINDINGS AVAILABLS 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? "'22e. AYES 0 N DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) April 15, 2019 To be completed by CORONER'S PhD SICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH isb. DATE SIGNED No., Day, Yr.) April 18, 2019 _..e. TIM CT CEitT11 08:50 PM _=c. PRONOUNCED DEAL (Mc. Day Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(a) stated. (Signature and Title) Daniel B. Einspahr, 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? ❑ YES E NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ENO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Daniel B. Einspahr, MD, 715 N Saint Joseph Ave, Hastings, Nebraska, 68901 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 29, 2019