202103095 - Laserfiche WebLink

Browse

ribr/arM 01xtADD»`tirYirlAyva�ioo8lN lfft4/lJlcieaQZ\Z terra �%Irlaa t OF NEBRASKA �uv„adrosx ztasli9A�ict au„ $4�taeetleig WOW r'Ill�,txraww mat WHEN € THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 2/22/2021 LINCOLN, NEBRASKA 202103095 SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 21 02288 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Kenneth Dahms 2. SEX Male 3. DATE OF DEATH ,(Mo.,,Day, Yr.) February 11, 2021' 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Farwell, Nebraska 5a. AGE - Last Birthday (Yrs.) 93 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 6. DATE OF BIRTH (Mo., Day, Yr.) January 14, 1928 7. SOCIAL SECURITY NUMBER 507-28-4390 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island OTHER ❑ Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) 18d. COUNTY OF DEATH Hall ❑ Hospice Faciftty, 9d, STREET ANL) NUMBER 517 Johnson Dr. Be. APT. NO. 9f. ZIP CODE 68803 9g. INS. iDE.CITY LIMITS YE$ Q. NO 1Oa. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Ellamae Schuyler 11. FATHER'S -NAME (First, Middle, Last, Suffix) Senjiman Dahms 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Pauline Dilla 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 05/16/1945-07/24/1946 14a. INFORMANT -NAME Ellamae Dahms 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ®"Burial ❑ Donation 0 Cremation: ❑ Entombment ❑ Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE Stacie L Cook 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) February 17, 2021.: 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery CITY / 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 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events. 411 , injuries, or complications.that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: a) Subarachnoid Hemorrhage IMMEDIATE CAUSE (Final disease ""n"" resulting irtde8th) Sequentially list conditions, If any, leading to the cause listed online a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Fall (dtsewe or injnrythatlnitiated DUE TO, OR AS A CONSEQUENCE OF: b)Head Trauma the events resulting In death) LAST 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death 2 Weeks onset to death 2 Weeks onset to death 2 Weeks DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART U. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Subdural Hernatoma, Antiplatelet Medications onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE:. ❑ Not pregnant within past year 0 Pregnant 8t rima ea death: ❑: Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) January 28 2021 21a. MANNER OF DEATH 0 Natural ❑ Homicide E Accident 0 Pending Investigation 0 Suicide 0 Could not be determined 22b. TIME OF INJURY 08:00 PM 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger ❑ Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ENO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site Home etc. (Specify) 22d. INJURY AT WORK? ❑ YES ®NO_ 22e. DESCRIBE HOW INJURY OCCURRED Patient fell from chair 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN 517 N Johnson Dr.; Grand Island n � J F5 u.'6 o 23a. DATE OF DEATH (Mo., Day, Yr.) February 11, 2021 23b. DATE SIGNED (Mo., Day, Yr.) February 12, 2021 23c. TIME OF DEATH 11:10 PM 23d. To the best of my knowledge, death occurred at the time, date and place and dna to the cause(s) stated. (Signature and Title) Travis S. Hageman, MD 25. DID TOBACCO U$E CONTRIBUTE TO THE DEATH? ❑ YEs al NO ❑ PROBABLY 0 UNKNOWN STATE Nebraska 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP CbDE 68803 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or investigation, In my opinion death decurred at the time, date and place and due to the cause(s) stated. (Signature end TWO 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ENO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE -% l /C2 -A gl /z�:r7 ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I February 19, 2021