|
2iA { ,.gq �j
<br />�3N6; ifASSSvM} yik( .41$FY�� fPCiNu k'l�M Ir4S,�,NFA.�ai�$Z��iQai,SYt E5YS fiPassrSlSSZ�.s1�1r,1�6}riri,�?�,1,eAro i �( J'A11'ty57 � i .ol�a� .i)�1,(4i(i?,(iyti`ull` } �Zili'�+'����� aflrl 5S3i�i)ii%d
<br />'STATE OF NEBRA;
<br />V,Y_ ati7 iC S A 2ttSNJNat .. taRCdt4'Ii1.r11NA:3x yWitSA`daa 'rrdyil('
<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 tl 2
<br />DATE OF ISSUANCE
<br />1/30/2020
<br />LINCOLN, NEBRASKA
<br />m
<br />i
<br />31
<br />1
<br />E
<br />4
<br />c
<br />fb-1
<br />E
<br />u
<br />0
<br />C
<br />a
<br />20220041]
<br />RUSSELL FOSLER.
<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. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Carol Lee Kenyon
<br />2. SEX
<br />Female
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Nelson, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-32-7953
<br />5a, AGE Last Birthday,
<br />(Yes.)
<br />86_
<br />Bb. FACILITY -NAME (If not Institution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a R.E$1DENCE-S1'ATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4152 Fleetwood Rd
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS,
<br />DAYS
<br />Se. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />ER/Otnpatient
<br />❑ DOA
<br />9c. CITY OR TOWN.
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 00803
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 20, 2020
<br />6. DATE OF BIRTH (Mo;;Day, Yr,J
<br />June 30, 1933
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS'
<br />® YES ❑ NO
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Harlon Leon Kenyon
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) : 12. MOTHER'S -NAME (Find,
<br />Wallace Hammell
<br />Sylvia Fifield
<br />Middle, Maiden Surname)
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Link.) No
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />0 Cremation ❑ Entombment
<br />0 Removal ❑ Other ;Specify)
<br />14a. INFORMANT -NAME
<br />Harlon Leon Kenyon
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />16b. LICENSE NO.
<br />1454
<br />14b. RELATIONSHIP TO DECEDENT::::
<br />Spouse
<br />16c. DATE (Mo., Day. Yr.)
<br />January 24, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, Statq)'.
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />CITY /TOWN
<br />Grand Island•
<br />STATE
<br />NebtaS.ka
<br />17b.,1;ip Coda
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />lb. PART I. Enter the chain of events -.diseases, injuries, or complications -that directly caused the (teeth. DO NOTent rterminal events such as cardiac arrest,
<br />reepiratery arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Dementia
<br />di or condition resulting
<br />Sequentially int condition. If
<br />any, feeding !tithe cause listed
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease Or injury Met initiated
<br />the events reaultinp in death)
<br />LAST
<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 />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 42 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />alb. IF TRANSPORTATION INJURY
<br />° ❑ Driver/Operator
<br />❑ Passenger
<br />Pedestrian
<br />0 Other Mooney)
<br />APPROXIMATEi)NTERVAI,
<br />onset to deal
<br />Years
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER � CONTACTED?T
<br />DD ❑ YES' NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 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 & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 20, 2020
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />January 23, 2020
<br />23c. TIME OF DEATH
<br />08:27 PM
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature end Title)
<br />Travis, S. Hageman, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opMion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 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
<br />January 24, 2020
<br />
|