|
h�ill�r r1'AriA�� f IA r IiNAk
<br />f 11e44�� y%11 1
<br />Na {J%I.iia,.
<br />. ,t r ¢ ttttr
<br />1In : a , > tl /
<br />11 of r4r � t Irl ��t1,
<br />i14
<br />�1 ( s .4
<br />Ji n
<br />r � I r D . r $r,i9 r 1
<br />I ) � ( t , 111 '� s.ue$...aai�ur . , .
<br />i /� qy as 1 , ,F , . , ztt,.d.)...Ei,).,I,�.
<br />yrr4f�((Gr4anC;lpa����1`:S�&kFfi'JAI!i��'�i3a,lr�i,4�ii.(€itre.duyi�3.f,Sd,dAt.EE,rel.)SfPda.E,ln��a. ,u ...i/x,AMau$� �(�uJu�ian��
<br />STATE OF NEBRASKA
<br />Y 4aidageWs NNW, .`coimiW i»'?446 ....
<br />4}YYv..
<br />lii�y'��4Fi ' 441))0
<br />a`s4r++lFD��
<br />yr, .;.
<br />N1/1 5'
<br />,I,u! n.Staii i)111111iiI1%srPtP.Mrl �� a,
<br />„r, C(M1 ��, a nrr , ell)
<br />S ,itl a s )3
<br />My ii�'r 1 ai "C j )))))
<br />1110
<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 />DATE OF ISSUANCE 20200023
<br />11/14/201 7
<br />LINCOLN NEF RASKA
<br />Car
<br />STANLEY S.'COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gretchen Ruth Buss
<br />4. CITY4ND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bertha, Minnesota
<br />7. SOCIAL SECURITY NUMBER
<br />475-46-3375
<br />8b, FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St Francis
<br />Q
<br />Lv
<br />w 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />c Grand Island, 68803.
<br />90. RESIDENCE -S'T'ATE
<br />D' Nebraska
<br />LL 9d. STREET AND NUMBER
<br />,, 1128 South Cherry Street
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />75
<br />5b. UNDER 1, YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL El Inpatient
<br />0 ER/Outpatient
<br />Q DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 7, 2017
<br />8. DATE OF BIRTH (Me-. Day, Yr ►
<br />February 25, 1942
<br />OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS ATTIME OF DEATH ®Married ❑Never Married
<br />❑ Married, but separated', ❑ Widowed 0 Divorced 0 Unknown
<br />s
<br />11. FATHER'S -NAME (First; Middle, Last, Suffix)
<br />I Martin Gustave Kirsch
<br />I 13. EVER4N U.S. ARMED FORCES? Give dates of service if Yes.
<br />y {Yea, No, or Unit.) NO
<br />.t 15. METHODOF DISPOSITION 16a. EMBALMER -SIGNATURE
<br />2 ® Burial ❑ Donation
<br />0 Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />1Ob. NAME OF SPOUSE (First, Middle,
<br />Duane Arthur Buss
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />YES ❑ NO
<br />Last, Suffix) If wife, give maiden name
<br />12. MOTHER'S -NAME (First, Middle,
<br />Myrtle Catherine Naslund
<br />Maiden Surname)
<br />14a. INFORMANT -NAME
<br />Duane Arthur Buss
<br />Katie M. Smvdra
<br />16b. LICENSE NO.
<br />1454
<br />14b. RELATIONSHIP TO, DECEDENT
<br />Husband
<br />16c. DATE (Mo., Day, Yr.)
<br />November 13, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />1. PART I. Enter the chain of eVe ts- -diseases, injuries, or complications -that directly caused the death. DO NOTentertenninalevents such as cardiac arrest,
<br />respiratory arrest,orVentriCUlar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 1 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Ventricular Tachycardia
<br />disease or condition resulting
<br />itt death)
<br />SequenUaly ilo4 candhions,)f
<br />any, leading to the cause setae
<br />on line -a
<br />DUE TO, OR A CONSEQUENCE OF:
<br />b) Myocardial Infarct
<br />STATE
<br />Nebraska
<br />17b. Zio Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset t0 death
<br />48 Hours
<br />onset t0: death
<br />48 Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />Ii SeaFF at' itt)atry etut4 tnItNNte4
<br />rt'# et death(
<br />317' events resuai
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Diabetes
<br />uj >, IF FEMALE:
<br />" ® Not pregnant within past year
<br />EL
<br />(WJ 0 Pregnant at time of death
<br />• ❑ Not pregnant. but pregnant within 42 days of death
<br />0 NO pregnant, Out pregnant 4 days to 1 year before death
<br />0 Uwknewrt (f pregnant within the past year
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />. INJURY AT WORK?
<br />❑YES ❑NO
<br />21a. MANNER OF DEATH
<br />Natural - ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other(Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES NO
<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 8, NUMBER, APT.NO.
<br />234, DATE OF DEATH (Mo., Day, Yr.)
<br />November 7 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 8 201
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />06:00 AM
<br />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 Title)
<br />Ryan; O. Crouch, DO
<br />25. DID TOBAC00 USE OQNTRIBUTE TO THE DEATH?
<br />❑'YES I NO ❑ PROBABLY 0 UNKNOWN
<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 time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN; CONSIDERED?
<br />0 YES ii e
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S
<br />SIGNATURE xi_ a,.
<br />28b. DATE FILED BY REGISTRAR{Mo„;Day, Yr.)
<br />November 9, 2017
<br />
|