|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT,.
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPO
<br />DATE OF ISSUANCE
<br />02/14/2014
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HW
<br />CERTIFICATE OF DEATH
<br />202110484
<br />IT CERTIFIES
<br />1'`H AND
<br />NtEY S. COOPER:
<br />I$TANT STATE R
<br />*OM QF"
<br />:SSR
<br />-i44 00656
<br />To be completed/verified by: FUNERAL DIRECTOR l
<br />1. DECEDENT'S•NAME (First, Middle, Last, Suffix) ^2
<br />Leo Charles Stamer
<br />SEXR "", T,. ' !'
<br />_ Mali X , •
<br />,
<br />3: 0 0FrOdA,14 (Mo., Day, Yr.)
<br />-Y item7, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY \
<br />413/RE bF BIRTH (Mo., Day, Yr.)
<br />Hastings, Nebraska
<br />(Yr..)
<br />80
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 23, 1933
<br />7. SOCIAL SECURITY NUMBER
<br />506-38-7038
<br />8a. PLACE OF DEATH
<br />MEM ❑ Inpatient OTHER ® Nursing Hom&ILTC 0 Hospice Facility
<br />Bb. FACILITY•NAME Of not Institution, give street and number)
<br />Tiffany Square Care Center
<br />0 ERIOutpatient 0 Decedent's Home
<br />0 DOA 0 other (Specify)
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCESTATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />212 East 22nd Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />12 YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH II Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Joan Karr
<br />11. FATHER'S -NAME (First, Middle, Last, SUfflx)
<br />Henry D Stamer
<br />12. MOTHER'S•NAME (First, Middle, Maiden Surname)
<br />Helena 0 Theesen
<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 />Joan Stamer
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER4IGNATURE
<br />Kevin Wood
<br />16b. LICENSE NO.
<br />1325
<br />16c. DATE (Mo., Day, Yr.)
<br />February 10, 2014
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston-Butler-Volland Funeral Home, 1225 N. Elm, Hastings, Nebraska
<br />17b. Zip Code
<br />68901
<br />L J
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />10. PART I. Enter the chain of events - diseases, Injuries, or compllatlonsdtal directly caused the death. DO NOT enter terminal events such as cardiac arrest, = APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etlology. DO NOT ABBREVIATE. Eider only one awe on a line. Add additional linos N necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Ischemic Cardiomyopathy
<br />disease or condition resulting
<br />onset to death
<br />3 Years
<br />M death) DUE TO, OR AS A CONSEQUENCE OF:
<br />s.quenlbty net condition., If b) Coronary Artery Disease
<br />any, leading to the cause listed
<br />onset to death
<br />6 Years
<br />on linea. DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />Error the UNDERLYING CAUSE •c) I
<br />(disease or injury that initiated
<br />the events resulting in dead') DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condltions contributing to the death but not resulUng In the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ PregnaM at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 DrivedOp.rator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®ND
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />ID Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown N pregnant within the past year
<br />seclude Could not a determined
<br />❑ ❑
<br />Pedestrian
<br />0 Oster (Seedy)
<br />21d. WERE AUTOPSY FINDINGS AVARABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 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 ahs, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />is
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 7, 2014
<br />To be completed by
<br />CORONER'S PHtt81C1AN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />Y
<br />z
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />February 11, 2014
<br />23c. TIME OF DEATH
<br />12:40 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />0
<br />1
<br />M
<br />23d. To the haat of my knowledge, death occurred at the tiros, dab and plea
<br />and Ow to the cause(s) stated. (Signature and T Ise)
<br />David R. Colan, MD
<br />24e. On the basis of examination and/or imestigatlon, in my opinion death occurred at
<br />the thin, date and place and due to the aumN.) Stated. (Slgraswa and TEM)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN 0 YES
<br />' •
<br />ATION BEEN CONSIDERED?
<br />-Not
<br />26b. WAS CONSENT GRANTED?
<br />Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />David R. Colan, MD, 729 North Custer Avenue, Grand Island, Ne 3
<br />•
<br />28a. REGISTRAR'S SIGNATURE A -
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 12, 2014
<br />
|