|
,rat;,' 0,11lztir to, .:.<.e@itt 1i�1 /tttt)fid°' ,fir
<br />/rurzk��+t31�;){�d)�(((�i5rS4w�ia et�aarrYs49ry/3R .nss5i 93ptlt
<br />y092 1)frriiu�:ia��hSSSM!4 ii�hr".11�Sz1r of ta�kl
<br />resided at the ti
<br />f&
<br />9
<br />d
<br />1
<br />E
<br />,1.c1��@U1Wil�/g��sualCSSta�i�lAlS el�iiatea�l$4��(�1�I�itl!'/,S��vnmoaa�9)atlflhi9i14<29ii!1u
<br />,:ece�(rrr , ,.
<br />I%i�`�1@PPi'f+'6a,4'(��1163r['N1i)"LFi'eta'h'���(iPrlltalncd3E�!'frr��E��l��r�ila5l��i)11�3�rfliQ
<br />f�Vjgr ((33,i ft ''77 yrr' (i(f555W�1 a �!t )Y71{ (( (ffrrrrl/,
<br />Oyli(.�rfFOtaL? N(�IfRir.)IJg1 : 6.��iPia ua'ye✓MMfff'ai i
<br />M „7o�S,,;66TYtYY;Y.tB�t?x _ sav55A5Wdt1: .zer4ye47i
<br />WHEN THIS :;'COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES TRE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />202001017 RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF IEAL.TH ANO HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />1/22/2020
<br />UNCOLN, NEBRASKA
<br />1.OECEDENT$ NAME (First, Middle, Last, Suffix)
<br />Julia Adrian Foote
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />New Orleans, Louisiana
<br />7. SOCIAL SECURITY NUMBER
<br />505-78-8023
<br />5a. AGE - Last Birthday
<br />(Yrs )
<br />Eb ;FACILITY -NAME (If notinstltutlon, give street and number)
<br />Wedgewood Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />56
<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 0 Inpatient
<br />❑ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)"
<br />January 13, 2020
<br />8. DATE OF BIRTH (Mo., Day, Yrj
<br />August 22, 19#
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c, CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER'
<br />2513 Commerce Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS"
<br />M YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />© Married, but sopa rated :; ;❑ Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Donovan B Foote
<br />13. EVER IN U.S.. ARMED FORCES? Give dates of service if Yes.
<br />(Yet1 No, or Link.) No
<br />15. METHOD; OF DISPOSITION
<br />❑ Burls, 0 Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other(Specify)
<br />10b. NAME OF SPOUSE (First, ,Middle, Last, Suffix) If wife, give maiden name
<br />Kris Mleczko
<br />12. MOTHER`S-NAME (First, Middle, Maiden Surname)
<br />Kathleen Moran
<br />14a. INFORMANT -NAME:
<br />Kris Mleczko
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />(Rt. LICENSE NO.
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />BV Cremation Center
<br />17a. FUNERAL HOME NAME:AND MA UNG ADDRESS (Street, City or Town, State)':
<br />Livingston-Butler-Volland Funeral Home, 1225 N. Elm. Hastings. Nebraska
<br />Hastings
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a PART i. Entgt the Olin Of events -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal swans such es cardiac arrest,
<br />retpiratery arrest, or tenMN$Aar fibrillation without showing the etiology. DO NOT ABBREVIATE. Entsr only one cavae one line.. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />IMMEDIATE CAUSE (Final
<br />dismiss or condition resulting
<br />In Wath) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequent/MN Pet cendhsone,rr >b)MetastaticAdenocarcinoma Of The Lung
<br />any, leading tethe cause INted
<br />on linea
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Emer the UNDERLYING CAUSE c)
<br />;disease or injury that initiated
<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 I.
<br />2t1. IF FEMALE:
<br />® Not pregnant within past year
<br />0 Pregnant M dme of death
<br />❑ Not Pregnant, but Pregnant. within 42 days of death
<br />0
<br />Not pregnant, but pregnant 49 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />0 YEs 0 N
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />INJURY
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (Mo., Day Yr.)
<br />January 16, 2020
<br />STATE
<br />Nebraska
<br />17b.Zip Oode
<br />68901
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />< 1 Week
<br />onset to deaeatt
<br />> 1 Year
<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 & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 13. 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 15.2020
<br />CITY/TOWN
<br />23e. TIME OF DEATH
<br />12:40 AM
<br />3d. To the beat o1 my knowledge, death occurred at the rima, date and place
<br />and due to the cause(a) stared. (Signature and Title)
<br />Jennifer L. Brown, MD
<br />25. =TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES Ea NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a, DATE SIGNED (Mo., Day, Yr.)
<br />24c.' PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />244. On the basis of examination and/or Investigation, in my opinion Wath occurred at
<br />the time, date and place and due to the ause(s) stated. (Signature and Mel
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN: CONSIDERED?
<br />❑ YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?:.
<br />Not Applicable If 28a Is NO 0 YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo.
<br />January 16, 2020
<br />
|