201906991 - Laserfiche WebLink

Browse

ngipq OM" kr f,( jjll())) s) t4aai , 3 1�(J �� Cattta&t 132 ta�Srils7Jaaanit �1 ) a'c°aiueetioxi;) oi;,;1 ':1.rC STATE OF NEBRA I�(IZttxraalalr skRitp/.yq�yy 3a st%,tyyy}Nt.0 z4i ..... d .. X-+..+..�. �,rFrM.t�t� i2Cx✓.•i3-x'=. _:. : °..i x: �tl Nt$9s` " 554tttttlIlly 4f 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 de DATE OF ISSUANCE RUSSELL FOSLER 9/4/2019 LINCOLN, NEBRASKA 20190699] ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Dale John Rohweder 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) August 27, 2019 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cairo, Nebraska 7. SOCIAL SECURITY NUMBER 506-42-4821 Se. AGE • Last Birthday (Yrs.) Sb. FACILITY -NAME (If not Institution, give street and number) 33 Via Trivoli 83 Sb. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/Outpatient ❑ DDA HOURS MINS. 6. DATE OF BIRTH (MO. Day, Yr.) September 12,1935 OTHER 0 Nursing Home/LTC ® Decedent's Home 0 Other (Specify) 0 Hospice Facility 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. REBIDENCESTATE Nebraska Bb. COUNTY Hall 9c. CITY OR TOWN Grand island 9d. STREET AND NUMBER 33 Via Trivoli 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITYLIMITS'' E YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married 0 Married, but separated, 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF. SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Betty Snodtrass 11. FATHER'S -NAME (First, Middle, Last, Suffix) George Rohweder 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ella Martha Louise Meyer 1a. EVER IN U.S.;ARMED FORCES? Give dates of service if Yes. (Yes, No or Unk.) NO • 14a. INFORMANT -NAME Betty Rohweder 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial 0 Donation E Cremation 0 Entombment ❑Removal 0 Other(Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 1Sc. DATE (Mo., Day Yr.) August 29, 2019 18d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services 17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska CITY / TOWN Gibbon STATE Nebraska 17b Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter Me Chain of events- diseases, Injuries, or complicatlons.hat directly caused the death, DO NOT entsrterminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a lute. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Pseudomyxoma Peritonei jn death) Sequentially list Conditions. any, leading to the cause listed on line it Enter the UNDERLYING CAUSE (dlseass or injury that initiated: the events resulting in death) LAST:; . DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) APPROXIMATE INTERVAL. onset to death 20 Years onset to death 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. 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death 0 Net pregnant, but pregnant 43 days to 1 year before death ❑ Unknown it pregnantwi0an the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑YES .0NO 21a. MANNER OF DEATH E Natural 0 Homicide ❑ Accident 0 Pending Investigation 0 Suicide 0 Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger Pedestrian Other (Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ENO 21c. WAS AN AUTOPSY PERFORMED? D YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH?. ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) August 27, 2019 CITY/TOWN 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH August 29, 2019 07:11 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Kenneth Vettel, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO 0 PROBABLY 0 UNKNOWN STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 7 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑'YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)- August r.)August 29, 2019 CD CA)