202007804 - Laserfiche WebLink

Browse

STATE OF NEBRASKA 202007804 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT :a_ x + TH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR,VIT II,,.RECQ QS< DATE OF ISSUANCE 07/06/2015 ,LINCOLN, NEBRASKA „ 4 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND II(IMAN .SER3/ICES CERTIFICATE OF DEATH• i a 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Garry Lee Williams 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island Nebraska 5a. AGE - Last Birthday (Yrs.) 62 5b. UNDER 1 YEAR MO& DAYS 03867 t � A 3 #4F"DEA7fR (Mo., bey. Yr.)- S. MATE eii SIRTr (M0. Day, Yr.) November 8, 1952: ,`Ri RIifdav, HOURS AIMS., 7. SOCIAL SECURITY NUMBER 505-64-1952 8b. FACILITY -NAME (H not Institution, give street and number) Own Propert'j 610 Midaro Drive Sa. PLACE OF DEATH HOSPITAL 0 Inpatient QILI R ❑ ER/Outpatient ❑ DOA ❑ Nursing Home/LTC ❑ Hospice Facility pDecedent's Home ® Other (speclfyiin a boat on pond Sc. CITY OR TOWN Grand Island OF DEATH (Include Zip Code) 6A801 rad. COUNTY OF DEATH it Hall 9a. RESIDENCE -STATE Nebraska Sib. COUNTY Hall CITY OR TOWN Grand Island 9d. STREET AND h UMBER 610 Midaro Drive 9e. APT. NO. 9f. ZIP CODE 68801 99. INSIDE CITY UNITS I YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) K wife, give maiden name Jeanne Susan McDonald 11. FATHER'S -NAME (First, Middle, Last, Suffix) Richard Grover Williams 12. MOTHER'S -NAME (First, Middle, Malden Surname) Marcella Dean Steffen 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or UnI .) No 14a. INFORMANT -NAME Jeanne Susan Williams 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF D SPOSITION ® Burial 0 Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER -SIGNATURE Katie M. Smydra 18b. LICENSE NO. 1454 tee. DATE (Mo., Day, Yr.) June 30, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY I TOWN Grand Island STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See Instructions and examples) i 1S. PART I. Enter thee& of events -diseases, Injuries, or compllcatlons4Mt directly caused the death. DO NOT anter terminal events such as cardiac ansa, respiratory arta , or ventricular nbnitalon without showing the etiology. DO NOT ABBREVIATE. Erna only one cause on • line. Add additional lbws If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE Final e) Unknown Natal al Caueee disease or condition resulting In death) Sequentially list conditions, If any. leading to the cause listed on Enter the UNDERLYING CAUSE (disease or Injury that inmate the events resulting in death) LAST APPROXIMATE INTERVAL onset to death. I!witediette DUE TO, OR AS A CONSEQUENCE OF: b) onset to death DUE TO, OR AS A CONSEQUENCE OF: C) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) h onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS-Condldons contributing to the death but not resulting In the underlying cause given In PART I. Hypertension, Ilyperlipidemia, Gout, Hyperglycemia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant et time of death 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 21a. MANNER OF DEATH Natural 0 Homicide 0 Accident 0 Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ DrivedOper,tor ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF IN.. URY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At hone, fano, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? OYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE I 23a. DAIE OF DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 24a. DATE SIGNED (Mo., Day, Yr.) July c, 40 15 24c. PRONOUNCED DEAD (Mo., Day, Yr.) June 26, 2015 24b. TIME OF DEATH Approx. .rt',..... ... 24d. TIME PRONOUNCED DEAD 07:21 AM 24e. On the basis of examination and/or Investlgatlon, in my opinion death occurred at the time, dote and place and due to the causes) stated. (Signature and"! Itle) Sarah Carstensen, Chief Deputy Hall County Attorney 25. DID TOBACC 5 USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? YES 0 NO 0 PROBABLY ® UNKNOWN 0 YES ® NO 27. LAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sarah Carstensen, Chief Deputy Hall County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 26b. WAS CONSENT GRANTED? Not Applicable if 26a 1s NO 0 YES 0 NO 28a. REGISTRAR'S SIGNATURE 16 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 6, 2015 i