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STATE OF NEB
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<br />a
<br />2001887
<br />Day, Yr.}
<br />Day, Yrl
<br />447-40.7263 HOSPITAL © Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME Ilf not Institution, give street and number) [] ERlOutpatient ®Decedent s Home
<br />2619 Cochin St 0 DOA ❑ Other (Specify)
<br />8e. CITY' OR TOWN OF PERTH (Include Zip Code) ad. COUNTY OF DEATH
<br />Grand Island 69801 ( Hall
<br />COUNTY
<br />9c. CITY OR
<br />C 0 . Unimown H pragnantwhin the past year ❑ YES ❑ NO
<br />r.
<br />,l? 22a, DATE OF tNJURY{Mo Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, famr. street, factory, office building, construction site, 611C.00 -110
<br />0-11y}
<br />22d. INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br />22f, ROGATION OF INJURY' •'<STREET 6 NUMBER, APT.NO. CITY/10WN STATE ZIP COPE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />a February 5, 2020 ir
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. 71ME OF DEATH y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />6 F 1 20,2n04:4
<br />K TO the but of my knowledge, dash occurred at the time, data and Plica
<br />246. On the basis of examination andfor Investigation, in my opinion death ocoturee at
<br />$ and due to the cause(s) stated. (Signature and Title) a the lime, Ants and place and due to the cause(s) stated. (Signature and Tft)
<br />Mathew Dav, MD D a
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ PROBABLY ❑UNKNOWN ❑ YES NO Not Applicable H 28a Is NO YES ❑ N
<br />27. NAME, TITLE AND ADDRE33 OFCERTIFIER (Type or Print)
<br />Mathew Day, MD, 729 N Custer Ave, Grand Island, Nebraska,' 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 18, 2020
<br />Id. STREET AND NUMBER:
<br />e. APT. NO.
<br />9f. ZIP CODE
<br />lig. INSIDE CITY UMIT8
<br />2619 GOchin St
<br />68801
<br />tR YES ❑ISO
<br />108. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Suffix) If wife, give maiden name
<br />v
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Ronald Dean Porter
<br />IMMEDIATE CAUSE:
<br />; onset to death
<br />11. FATHER'S -NAME (First, Middle, Last Suffix)
<br />12. MOTHER'S -NAME (First,
<br />Middle, Maiden Surname)
<br />Arthur, Phillips Harris
<br />CallieLouise Hunter
<br />In dada DUE TO, OR AS A CONSEQUENCE OF:
<br />13. EVER IN U.$ ARMED FORCES? Give dates of service if Yea.
<br />14a. INFORMANT -NAME
<br />Sequentially list conditions, R b) Hyponatremia
<br />14b. RELATIONSHIP TO DECEDENT
<br />u
<br />(Yes, No, or unit.) No
<br />Ronald Porter
<br />'O
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<br />Souse
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<br />18. METHOD OF DISPOSITION
<br />18a. EMBALMER -SIGNATURE
<br />18b. LICENSE NO.
<br />Ilio. DATE (Mo., Day,. Yr.)
<br />; - .
<br />❑ Burial ❑ Dcmdon
<br />Not Embalmed
<br />r onset to death
<br />February 7, 2020
<br />M
<br />®Cremation ❑ Entomt)ment
<br />_
<br />❑°Removal ' ❑Other (Specify)
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN
<br />STATE
<br />°u
<br />Metastatic Small Cell Lung Carcinoma, History Of Breast Cancer, Asthma, COPD, Anxiety, Depression, Insomnia, GERD,
<br />Central Nebraska Cremation Services Gibbon
<br />Nebraska
<br />w
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />171r. Zip Coda.
<br />s
<br />AN Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />21a. MANNER OF DEATH
<br />68801
<br />C 0 . Unimown H pragnantwhin the past year ❑ YES ❑ NO
<br />r.
<br />,l? 22a, DATE OF tNJURY{Mo Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, famr. street, factory, office building, construction site, 611C.00 -110
<br />0-11y}
<br />22d. INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br />22f, ROGATION OF INJURY' •'<STREET 6 NUMBER, APT.NO. CITY/10WN STATE ZIP COPE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />a February 5, 2020 ir
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. 71ME OF DEATH y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />6 F 1 20,2n04:4
<br />K TO the but of my knowledge, dash occurred at the time, data and Plica
<br />246. On the basis of examination andfor Investigation, in my opinion death ocoturee at
<br />$ and due to the cause(s) stated. (Signature and Title) a the lime, Ants and place and due to the cause(s) stated. (Signature and Tft)
<br />Mathew Dav, MD D a
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ PROBABLY ❑UNKNOWN ❑ YES NO Not Applicable H 28a Is NO YES ❑ N
<br />27. NAME, TITLE AND ADDRE33 OFCERTIFIER (Type or Print)
<br />Mathew Day, MD, 729 N Custer Ave, Grand Island, Nebraska,' 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 18, 2020
<br />CAUSE OF DEA See Instructions and examples)
<br />18. PART 1. Enter the thein of events- -dis aves, Injuries, or camplications4hat directly caused the death. DO NOT enter terminal events such as cardiac arfest,
<br />, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add additional Imes IF necessary.
<br />IMMEDIATE CAUSE:
<br />; onset to death
<br />IMMEDIATECAU.SE (Final a) Respiratory Failure
<br />3 DaV$
<br />dissent or condition moo"
<br />;
<br />In dada DUE TO, OR AS A CONSEQUENCE OF:
<br />' onset to death
<br />Sequentially list conditions, R b) Hyponatremia
<br />15 Months
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<br />any, leading to the. cause Fated
<br />'
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<br />d
<br />on line A.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />; onset to death
<br />Enter t of uDER YIN(ICAuse' e) Syndrome Of Inappropriate Anti -diuretic Hormone
<br />15 Months'
<br />(disisfr or Irdu"at InideteA
<br />; - .
<br />as events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />r onset to death
<br />LAST d)Metastatic Small Cell Lung Carcinoma
<br />15 Months
<br />m
<br />18. PART 11.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />Metastatic Small Cell Lung Carcinoma, History Of Breast Cancer, Asthma, COPD, Anxiety, Depression, Insomnia, GERD,
<br />OR CORONER CONTACTED?
<br />w
<br />Essential Tremor, Osteopenia
<br />❑ YES ® NO
<br />E0.
<br />IF FEMALE:
<br />21a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21a WAS AN AUTOPSY PERFORMED?
<br />© Not prsgnsidwMin psatyeer
<br />® Natural ❑Homicide
<br />❑ Ddver/oparstor
<br />❑ YES NO
<br />© Pregmsnt attune of death
<br />❑ Accident ❑ IrMdin9 Imestlgptfen
<br />Passenger
<br />y
<br />[3Not pregna 4but pregnant within 42 days of death
<br />❑ Suicide ❑ Could not be determined
<br />❑ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVA►LA
<br />❑ Not pregnant, but pregnant N days to t you Wore death
<br />❑Other (Specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />C 0 . Unimown H pragnantwhin the past year ❑ YES ❑ NO
<br />r.
<br />,l? 22a, DATE OF tNJURY{Mo Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, famr. street, factory, office building, construction site, 611C.00 -110
<br />0-11y}
<br />22d. INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br />22f, ROGATION OF INJURY' •'<STREET 6 NUMBER, APT.NO. CITY/10WN STATE ZIP COPE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />a February 5, 2020 ir
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. 71ME OF DEATH y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />6 F 1 20,2n04:4
<br />K TO the but of my knowledge, dash occurred at the time, data and Plica
<br />246. On the basis of examination andfor Investigation, in my opinion death ocoturee at
<br />$ and due to the cause(s) stated. (Signature and Title) a the lime, Ants and place and due to the cause(s) stated. (Signature and Tft)
<br />Mathew Dav, MD D a
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ PROBABLY ❑UNKNOWN ❑ YES NO Not Applicable H 28a Is NO YES ❑ N
<br />27. NAME, TITLE AND ADDRE33 OFCERTIFIER (Type or Print)
<br />Mathew Day, MD, 729 N Custer Ave, Grand Island, Nebraska,' 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 18, 2020
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