202105458 - Laserfiche WebLink

Browse

I :I o k li t,ttl iloedeed;1111,Eltlkaa ttili)aa eel arw,t dtlfllill4)&o`l int �' IAw aa,"' -" ttt11t11RII W: ? tlltwiwo llttr @hear y :fith tWINSte ref 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 1/19/2021 LINCOLN, NEBRASKA 202105458 (4'M_J-1 %R:f1.C.2ry SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 2019543 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death, 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Hubert Eugene Bishop 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) << December 30, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Bartlett, Nebraska (Yrs.) 86 MOS. DAYS HOURS MINS. January 16, 1934 7. SOCIAL SECURITY NUMBER 50740-0381 8a. PLACE OF DEATH HOSPITAL M Inpatient OTHER 0 Nursing Home/LTC 'Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1576 E. Prairie Rd Se. APT. NO. 9f. ZIP CODE 68801 99. INSIDE CITY tIMITS. Q YES E NO 10a MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married 0 Married, but separated 0 Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Elaine Janky 11. FATHER S.NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Su KathrynBishop Kathryn Sturek 13. EVER IN U.$. ARMED FORCES? Give dates of service H Yes. (Yes, No, or Unk.) Yes 02/02/1954-07/22/1955 14a. INFORMANT -NAME Elaine Bishop 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION 0 Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) January 4, 2021 Cremation 0 Entombment El Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska lie. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1$. 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, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Ertm only one rause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a)Acute Hypoxic Respiratory Failure disease or condition resulting onset to death Days In death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)COVID-19 Pneumonia any, leading to the cause listed on line a. onset to death Days DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or Injury that Initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1. Coronary Artery Disease, Acute Renal Failure, Laryngeal Cancer, Tracheostomy 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ENO 20. IF ❑ FEMALE: Not pregnant, within plat year Pregnant at time of death 21a. MANNER OF DEATH E Natural 0 Homicide El Accident 0 Pending Invaatigetan 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES O. NO ❑ Not pregnant, but pregnant within 42 days of death ElNot pregnant, but pregnant 43 days to 1 year before death 0 if pregnant within the past year 0 Suicide ❑Could not be determined Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 NO ,Unknown 22a. DATE OF INJURY (Ma., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22t. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) December 30, 2020 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 4. 2021 23c. TIME OF DEATH 08:20 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To tin best of my knowledge, death occurred at the time, date and place and due to the'cause(s) stated. (Signature and Title) Vinay K. Singh, MD 24e. On the basis of examination and/or Investigation, In my opinion death OCCurred et the time, date and place and due to the cause(s) stated. (Signature end Title) f; 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 0 NO "❑ PROBABLY E UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Vinay K. Singh, MD, 2620 W Faidley Avenue, Grand Island, Nebraska, 68803 Q 28a. REGISTRAR'S SIGNATURE _4 g `Jla 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 14, 2021