|
gIyyy�q*�arS sti p} Rt +ic: Kit?-+ fir'-+ � ,+�*3ax -t;•
<br />9rr83;tifaiiis,`T���#I�%It�1}1,et6tt�t���uR�.l�?I,?da�a$t�#III;i��B�r d�ciata�I���tlli`�
<br />;t44'9Nxt . conlo19tB1IImp J�+ttttntdiaIto p
<br />.'.. ,.,
<br />rrttfil l5'IIIfszea rdrom tL
<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 />10/1/2020
<br />LINCOLN, NEBRASKA
<br />0
<br />m
<br />E
<br />rs<
<br />2 0 210 9 6 7 V 'SARAH BOHNENKAMeiP
<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 />1. DECEDENT. S -NAME (First, Middle, Last, Suffix)
<br />Jayne Marie Westering
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Columbus, Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />507-79-9827
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />2015 West John St
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island . 66803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2015 West John St
<br />9b. COUNTY
<br />Hall
<br />10a MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />68
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 12781
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 16, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />August 3, 1952
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />0 Hospice Facility
<br />'9g. INSIDE CITY LIMITS.
<br />60 YES ❑ NO
<br />1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />William Beecher Westering
<br />11, MINER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Donald Uphoff Nelda Schaeffer
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />William Beecher Westering
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />curial ❑Donation
<br />13 Cremation ❑ Entombment
<br />Removal ' 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />18b. LICENSE NO.
<br />1495
<br />16e. DATE (Mo., Day, Yr.)
<br />September 19, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac inset,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />a) Dementia
<br />IMMEDIATE CAUSE (final
<br />disease or condition resulting
<br />In death)
<br />Sequentially list conditions, if
<br />any, leading to the caulk listed
<br />online a.
<br />Enter the UNDERLYING CAUSE
<br />(disuse or Injuiythat initiated
<br />the events resulting in death)
<br />LAST
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Yeats
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Chronic Kidney Disease
<br />onset to death
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE.:
<br />Not pregnant within past year
<br />0 Pregnane at lime of death
<br />Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑- Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending investigation
<br />❑ Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />O YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sits, etc(Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES .;❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 16, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />September 18, 2020 Unknown
<br />E u 0 0 ;3d. Tp the best Of my knowledge, death occurred at the time, date and piste
<br />try g and due tit the causes) stated. (Signature and Title)
<br />7 o
<br />e ~ 2 Travis S. Hageman, MD
<br />o.
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES Ea NO '❑ PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion deed) etcurtvd at
<br />the time, date and place and due to the causes) stated. (Signature and Title)'
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />September 28, 2020
<br />
|