|
/ 11
<br />1,1
<br />ni...
<br />k1)G,
<br />1
<br />I�t�y14`taa
<br />r
<br />�
<br />tl
<br />rhfV 3a�m
<br />11
<br />N \ L. 1 rl /
<br />/ D \ 1 \ 11111 1 /-. 1 TOdome,%\1 C1 /A 111 � 1 I \ / s;\ ( / \ 11 3 (I / \ i Z 111) 1 .e r rr ..\. 1.11,1 /, rie��. a r r,.1 A� e� \ (i O ne ,. euu 1/41/..>..1,A1...,,1/s?sa�...,11\,... ,tre..N(,.daiu.. u,. ...t., ,... , .. „u.(r r \ 11)y6/�d1'��r�i'OMailllll1f/�iw�i GAi\C ,1n,,//rl11`. fi,` Irrrrr �/4 I 1
<br />�,,Cin.44 11 §tti t)sis// 1 P 1�1 Z1�A �t+ti), aeu / ilh1A t Il :: hQ i' �t1 D eq¢SNrWA11e /d01r19111(1tt1" rrrii4'at r6471i1it11p11w ,rrrn,nl (�(llll
<br />STATE OF NEBRASKA
<br />WrE%) r, "`eatitAttN i111v`aV
<br />"4ttlra )iir�P'iNKi«4u'rvl;rr
<br />,as: a.��srr 1111 ��
<br />LolF / ,w21)",?
<br />li
<br />WHEN ' THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRt1E 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 />9/1/2020
<br />LINCOLN, NEBRASKA
<br />(1DECEOENTS=NAME{First, Middle, Last, Suffix)
<br />202007044
<br />'L. r)c9.�7 / 1/5 ..11 xtiketi#L
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Eugene Lorraine Pletcher
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bartlett, Nebraska.
<br />7 SOCIAL SECURITY NUMBER
<br />1 506-26»8752
<br />G 'Bb. FACILITY -NAME (if not Institution, give street and number)
<br />a)
<br />E
<br />Tiffany Square Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803''
<br />✓ 9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET ANQNUMBER
<br />2805 Circle Drive
<br />m
<br />s
<br />L
<br />E 11. FATHER'S -NAME (First,; Middle,
<br />Edwin Pletcher
<br />9b. COUNTY
<br />Hall
<br />ba. AGE - Last Birthday
<br />(Yrs.)
<br />90
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />2011273
<br />3. DATE OF DEATHIMO., Day, Yr.)
<br />August 21, 2020
<br />5. DATE OF BIRTH (MO., Day, Yr.)
<br />October 6, 1929
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Speedy)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />© Hospice Facility''
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />90. INSIDE CITY U$ITs
<br />YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated Ea Widowed 0 Divorced 0 Unknown
<br />1012. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />Ilene Bishop
<br />Last, Suffix)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />c (Yes, No, or Unk.) Yes 09/13/1950-02/26/1954
<br />4)
<br />0
<br />u
<br />16. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />❑ Crematibn 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Bernice Huff
<br />14a. INFORMANT -NAME
<br />Kimberly Jean Koch
<br />14b. RELATIONSHIPTO DECEDENT
<br />Daughter
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />August 26, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Hillside Cemetery North Loup
<br />:s 17a. FUNERAL HQME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />a All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska
<br />dr
<br />STATE
<br />Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />Z 111I. PART I. Enter the chain of events- •diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE Mimi a) Chronic Combined Systolic With Diastolic CHF
<br />diseaseor conditten resatNng
<br />m
<br />a
<br />m
<br />N
<br />In deaflil._„ DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, I b) ASCVD
<br />any, leading to the cause listed
<br />On linea,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />FJ 1 enter the UNDERLYiNO CAUSE C)
<br />6 (disease or injury that initiated
<br />4) the events resulting in death)
<br />LAST
<br />>:a
<br />0
<br />to
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />8. PART II, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />CKDStage IV, Chronic Cerebravascular Disease, Vascular Dementia, Type II Diabetes
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />>5 Years
<br />onset to death
<br />>20 Years
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />❑ Not pregnant wtthln pest year.
<br />0 Pregnant et time of death
<br />❑ Not ¢regnant, but pregnent within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown I pregnant within the past year
<br />2a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />[3 YES I=1 NO
<br />Nz
<br />tai
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES
<br />No
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22e. 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 />CITY/TOWN;'
<br />STATE ZIPs600E
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />August 21, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />August 24, 2920 11:26 PM
<br />NL To the -best of my kndwiedge, death occurred at the time, date and place
<br />and due to the cauae(s) stated. (Signature and Tale)
<br />Steven Husen, MD
<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 />24s, Onthe basis': of examination and/or Investlga Ion, In my opinion death bcptxred at
<br />thelUne, data and place and due to the cause(a) stated. (Signature and 71se)
<br />26a. HAS ORGAN OR TISSUEAONATlON BEEN CONSIDERED?
<br />0 YES Ea NO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />®:YES [3 NO. [3 PROBABLY 0 UNKNOWN
<br />. NAME, TITLEAND AGDWS OF CERTIFIER (Type or Print
<br />Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebrask
<br />28a. REGISTRAR'S SIGNATURE j
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 3 YES 0 NO
<br />68803
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 26, 2020
<br />
|