|
aNn/ii00 iatttSC?gNMOgnh a,; i 3 i i!l rfi i t��P�(4Slya •,.
<br />di/9Ee1�\. 11,,,, �f1.1
<br />��i111//aaf'
<br />Teal .u2Nh4i'NV�`t t4t81@sP'" . x.vrdGNAjAtstaf 4.�
<br />vHiiayiit)) „.
<br />t((a.,, 1i31�
<br />t•g;Pd1Ills
<br />$Elysr,(,1/111v
<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 />j
<br />DATE OFISSUANCE
<br />201906947 RUSSELL FOSLER
<br />9/6/2019 ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />LINCOLN, NEBRASKA
<br />E
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Letha Jeanie McIntosh
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Valentine, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-78-2058
<br />Se. AGE - Last Birthday 413. UNDER.1 YEAR
<br />(Yrs.) MOS. DAYS
<br />3b. FACILITY -NAME (if not Institution, give street and number)
<br />CHI Health St. Francis
<br />62
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 30, 2019
<br />6. DATE OF BIRTH (M4. Day, Yn).;,.
<br />September 1, 1956
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />« 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />ie
<br />c
<br />dr
<br />m
<br />b
<br />m
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />• Nebraska
<br />9d. STREETAND NUMBEit
<br />305 West 4th Street
<br />9b. COUNTY 9c. CITY OR TOWN
<br />Hall Alda
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated ; ❑ Widowed ® Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Bartlett
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68810
<br />9g. INSIDE CITY LIMITS'
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Letha Newland
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />u
<br />B
<br />c
<br />3
<br />3
<br />2
<br />t '
<br />1
<br />IMMEDIATE CAUSE:
<br />N le. death)
<br />;17
<br />dr
<br />Von tinea.
<br />t+
<br />d
<br />m
<br />t
<br />w
<br />20. IF FEMALE:
<br />E ® Not pregnant within past year
<br />O ❑ Pregnant at time of death
<br />L
<br />�3 ❑ Not pregnant, but pregnant within 42 days of death
<br />Gi
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown -if pregnant withingie past year
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />0 Cremation ❑ Entombment
<br />0 Removal >❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Jessica Valasek
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. HYronemus
<br />18b. LICENSE NO.
<br />1448
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)
<br />September 4, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Alda Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />CITY / TOWN
<br />Alda
<br />STATE
<br />Nebraska
<br />17b, Zip: Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART 1. Enter the chain of events -diseases, Injuries, or complications -that directly caused the death. DO NOT entertenninal events such as cardiac arrest,
<br />respiratoryarreat or ventrinutar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one rause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE (Final a) Pancreatic Carcinoma
<br />disease or condition resulting
<br />Sequentially iittt nondaions, d
<br />any, leading to the cause fisted
<br />DUE TO, OR AS A CONSEt.IUENCE OF:
<br />b) Diabetes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease Or fnjury:that initiated
<br />the events resulting:in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART H. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Other(Specify)
<br />APP ROIIIMATE:INTERVAL
<br />onset to dash;
<br />1 Year
<br />onset to death
<br />onset to death'>
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSYPERFORM£D?
<br />0 YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 30. 2019
<br />27i, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />z August 30, 2019 07:25 AM
<br />0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and This)
<br />Kenneth Vette), MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ®NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR
<br />0 YES
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD'
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the tkne, date and place and due to the cause(s) stated. (Signature and TRIe)
<br />ISSUE • • ATION;BEEN CONSIDERED?
<br />7 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kenneth Vette!, MD, 2116 W Faidley #400, Box 9802, Grand Island, -• - ,ka,, 68803
<br />28a. REGISTRAR`& SIGNATURE
<br />EXHIBIT
<br />I ``
<br />a
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 3, 2019
<br />
|