|
s1
<br />�
<br />i)I777( OMi10)•t ;; 43IIII i (I./ //,, t (f P/ )b)yc,Zt iltf &s& %l Q�t4 sitar.;' 44Oi,W1 a4604
<br />l CTAT 1 M D RA//�ySpy�y,K..1� A
<br />i4tY�,feaWR » . 4ntIt4VN{Q vu,p, TN,,A.
<br />ratrAtYluo .:2/,"Nt
<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
<br />3/18/2020
<br />UNCOLN, NEBRASKA
<br />20200.4 7 g1
<br />raf� .dits4tht.
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPATTMFl•TT nF Prz ".1,17:
<br />AND. HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />20 03229
<br />m
<br />esE
<br />m
<br />14
<br />2
<br />1. pECEDENVS.NAME (First, Middle, Last, Suffix)
<br />Janice Eileen Shafer
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (MO., Day, Yr.)
<br />March 9, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ogallala, Nebraska
<br />6a. AGE - Last Birthday
<br />rrea
<br />68
<br />5b. UNDER 1 YEAR
<br />6c. UNDER DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />INS.
<br />S. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 12, 1951.
<br />7. SOCIAL SECURITY NUMBER
<br />506-60-5469
<br />6b FACIUTY-NAME (It not Institution, give street and number)
<br />Tiffany Square Care Center
<br />8c. CITY OR TONIN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />ga. RESIDENCE -STATE
<br />Nebraska
<br />Id. STREET AND NUMBER
<br />1718 Ingalls Street
<br />9b. COUNTY
<br />Hall
<br />85. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S. AME (First, Middle, Last, Suffix)
<br />QrvilIe Lee Garrard
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />16. METHOD OF DISPOSITION
<br />g] Burial ❑ Donation
<br />Cremation ❑Entombment
<br />Removal 0 Other (Specify)
<br />u
<br />I
<br />9e. CITY OR TOWN
<br />Grand Island
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9¢ INSIDE CITY LIMITS
<br />I1] YES ❑ NO
<br />!Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) Ifwife, give maiden name
<br />William Dean Shafer
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />DeLois Mariean Madison
<br />14a. INFORMANT -NAME
<br />William Dean Shafer
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />1 16b. LICENSE NO.
<br />1092
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIONSHIP TO DECEDEN
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />March 16, 2020
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Durran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />g 18, PART I. Enter the chain of events- ddiseases, Injuries, or complication -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrestor or wntncoar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on amu. Aad adanional uses a necessary.
<br />IMMEDIATE CAUSE:
<br />• IMMEDIAtE CAUSE (Final a) Aspiration Pneumonia
<br />A*nese or corn! tion resulting
<br />I
<br />d
<br />V
<br />15
<br />M death)
<br />Sequentially Set conditions, R
<br />any, leading to the cause listed
<br />on fine e.
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)CEREBROVASCULAR ACCIDENT
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that initiated
<br />onset to death
<br />Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST _.. d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in 1h
<br />Lung Cancer CHRONIC OBSTRUCTIVE PULMONARY DISEASE
<br />underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />g .20. IF FEMALE:
<br />E ❑Natpnpmntwithin pan year
<br />2 ❑ Pregnat*tbnadaam
<br />g 0 Y',.. ,...e..to:, L. ,p:.et.:t.t .1::16,142 .ice s ..:.:...:..
<br />F0 Not pregnant, but pregnant 43 days to 1 year before death
<br />C E Unknown It pregnant within the pat year
<br />el
<br />e3'
<br />e
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident
<br />❑ Suicide
<br />❑ Pending Investigation
<br />❑ Could not be determined
<br />21b. IF TRANSPORTATION INJUR
<br />Onverrownstor
<br />❑,Passenger
<br />GYsdseb:sn
<br />❑ Other (specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES E NO
<br />2i...4E„CKu73F3,'P*3E,R4iGSiv.".:,lib a:
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO,...
<br />22a. DATE OF INJURY (Mos, Day, Yr.)
<br />22b. TIME OF INJURY
<br />22e. PLACE OF INJURY.At home, farm, street, factory, office building, construction site, etc. (S)
<br />22d. INJURY AT WORK?
<br />❑ YES , ,O NO
<br />22e. DESCRIBE HOW I."4URY OCCURRED
<br />22f LOCATION OF INJURY: STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />t
<br />z
<br />8 • o
<br />e
<br />0.
<br />23a- DATE OF DEATH (Mo., Day, Yr.)
<br />March 9 202
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 11.2020
<br />23c. TIME OF DEATH
<br />05:05 PM
<br />23d. To *helmet army knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion death tCturrird et
<br />the iia,., date and place and due to the cause(s) stated. (signature en4 Title)
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES 0 NO 0 PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO Q YES
<br />quo
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />)G Z4..% g az.en -,-K p.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 13, 2020
<br />i
<br />O
<br />CrN
<br />I;
<br />CO
<br />O
<br />
|