|
.t 1 a
<br />S
<br />1
<br />Vers , ) a
<br />,
<br />r
<br />yi
<br />0Y
<br />,.N a
<br />I
<br />e1) e i
<br />trr i'i'�1N( (1Pr r%•
<br />3 �.MN,�+aiSa� uM 1I d
<br />1 ..........................................
<br />(Y11i.. aazt+MPYO(J) r,p11 lattI4A'� rII�
<br />1 ,
<br />. \ .Z / '3 '611 , ..0 1 � , \ � 11
<br />1 1 i 1 .. INN 7
<br />i a s I s, 9 I t
<br />/ L Ih � , t0. 1 11 11 n �, ( ,
<br />I r ,,.. ) IAttE£E�II.zi7act.,laa1.,,,ibfi..ra7.Aar��iag,a,l„It A,.41,..�ac.,aa,l.a,uuuir()e r , 11 I 0.n
<br />ddt�l�££�1r%4mJAl���Y3�f� Art9�i,r„ u.,,�a.3) )U dlr4d`c»�i����lllddirR�,?d?sss Y))))£'+r
<br />"� STATE OF NEBRASKA
<br />IIIAs4ar anr4rn,a1, 4th.. q$4((�y11111�t�)$At$ t�rIJ.A�
<br />Itramtaast0. afI9Yt1II1ROs : 1x66 yeesa w*0.trey
<br />:.situ...... -..... ..T, . i..
<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 />10/27/2017
<br />LINCOLN, NEBRASKA
<br />202105858
<br />acipi
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND. HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Mgier nahZ))IIuldrlr�lllll 140.)1Z)))It
<br />n„igy 5th 41 i 1 ,,,�.t`.rtn fiij,
<br />nNl. rIli�, 111)x, . 3 a/61
<br />0
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Lucille Kathleen Cleveland AKA Kathleen Cleveland
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 21, 2017
<br />4, CITY AND STAT OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Boone County, Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />482-28-6192
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />tib, FACILITY -NAME (H not Institution, give street and number)
<br />CH.I Health St. Francis
<br />87
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH 1Mo.,.Day
<br />November 9, 4929
<br />8a. PLACE OF DEATH
<br />HOSPITAL M Inpatient OTHER 0 Nursing HomeILTC
<br />❑ ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify'
<br />0 Hospice Faculty
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand.;lsland.. 68803
<br />9a, RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1708 West Division
<br />9b. COUNTY
<br />Hall
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island'
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY OMITS
<br />® YES ❑ NO
<br />Ga. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated',' 0 Widowed 0 Divorced ❑ Unknown
<br />1Ob. NAME OF SPOUSE(First, Middle, Last, Suffix) If wife, give Maiden n
<br />Charles Rex Cleveland
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Lloyd Lewis
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Alta Lutz
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or (ink.) NO
<br />15. METHOD OF DISPOSITION
<br />Burial Q Donation
<br />0 Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Charles Rex Cleveland
<br />14b. RELATIONSHIP TO DECEDENT;
<br />Spouse
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16b. LICENSE NO.
<br />1191
<br />16c. DATE (Mo., Day, Yr.)
<br />October 26, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructipns and examples)
<br />76. PART I. Enter the Their or events- 'diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or veMncular fibrillation Without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on line, Add additional hoes N necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />Sequentially list conditions. it
<br />any, leading to the cause Wed
<br />•.
<br />on linea
<br />Enter the UNDERLYING CAUSE
<br />(disease or r1Fry that initiated .
<br />the eyhits talUltiflg::in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute On Chronic Systolic Heart Failure
<br />APPROXIMATEtNTERVAL::.
<br />Onset to death
<br />Immediate
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Severe Sepsis
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Pneumonia
<br />onset to death
<br />Days
<br />2
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Acute Renal Failure; Patient Transitioned To Comfort Cares And Passed On
<br />20. IF FEMALE-
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />0 Nat pregnant, but pnighant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ UnknwrM if pregnant whim the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22.d.:iNJURY AT WORK?
<br />❑YES 0 NO
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could tnet be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />Other(Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES ❑ ruo
<br />21c. WAS AN AUTOPSY PERFORMED/ I>
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY.: FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DPPJITH1
<br />❑YES NO
<br />22c. 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 IL NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />s October 21 i 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />• w J
<br />g v z
<br />u <Y 0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />Z a and due to the cause(s) stated. (Signature and TNM)
<br />e
<br />October 24. 2017
<br />23c. TIME OF DEATH
<br />01:30 AM
<br />` Michael A. Donner, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES Q NO ❑ PROBABLY 0 UNKNOWN
<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 />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN' CONSIDERED?
<br />❑ YES RI NO
<br />26b. WAS CONSENT GRANTED/
<br />Not Applicable If 26a Is NO 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a, REGISTRAR'S SIGNATURE 4,6 _ astpoz,R _
<br />28b. DATE FILED BY REGISTRAR (Mo,, bay, Yr.)
<br />October 24, 2017
<br />1
<br />0
<br />w
<br />00
<br />
|