|
rh 1)i(Iil�� rorm �\1111i1{I�lllliiir; ntrultqfiWil,lltr,4�Ur„tV;1111i1{}1�11r4:1; ,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THF NATE OF NEBRASKA,
<br />CERTIFIES THE DOCUMENT ' BELOW TO SCA : A 1 s COPY OF THE ORIGINAL RE
<br />•ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORt FOR 1/ITAL REGARDS
<br />DATE OFISSW NCE
<br />1 /13f20t9
<br />. 44NC0 N, NEBRASKA
<br />L --
<br />V 2 2ASSISTAUNT STATE REGISTRAR
<br />RFOSLER
<br />2 2c� ii'�� DEPARTMENT OF HEALTH •
<br />U tG s� hi� 'r AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPAR1MENT>O 'HEALTH.iAND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />IT
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Colleen Sue Holder
<br />Crt f ANDSTA..E OR TLt R1TORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand tslatld, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />.::,:505-38-7148
<br />b. FACILITY NAME (If not Institution, give Street and number);.
<br />CHI Health.:$t Francis
<br />8c. CITY OR TOWN OF LATH (Include Zip Code)
<br />Grand:.Island 68803 •
<br />9a R)~SJDENCEATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Sa AGE; Last.Btthday.
<br />!yK)
<br />80:ft
<br />6�. U.,NDER1 YEAR
<br />MOS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />EIlOutpatlent
<br />�D9A
<br />DAYS
<br />d. STREET AND NUMBER,
<br />722 E8th Street
<br />lila MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />E Manned but separatedis 0 Widowed 0 Divorced 0 Unknown
<br />11. FAT'HER'S-NAME:(Ftret, Middle, Last, Suffix)
<br />Thomas Korn
<br />13. EVER:IN U.S,.ARMED FORCES? Give dates of service If Yes.
<br />(Ye, No, or vox.))`is3
<br />tB INetHOD OF: C isri0.09 ON
<br />L ❑ ItrNal • "❑ Denatten
<br />5 • } Cremation 0 Entombment
<br />Removal] Other (Specify)
<br />39g,. CITY: OR TOWN:
<br />Grand !Bland
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />HOURS
<br />3. DATE OF DEATH (Mo., DaysYr.)
<br />PeCeIrber 2, 2019
<br />0. DATE OF BIR'I11.M+:iOayh'f`)::..
<br />Sd COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9p.'IMSIOE GtTYLtI rrir
<br />® YES 0 No
<br />10b. t FAME OF SPOUSE (FI[St, MIddIe, Last, Suffx) E wife, give maiden ImiK1
<br />Georste Lets Holder
<br />14a. INFORMANT -NAME
<br />George. Holder
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />12.140711E NAME
<br />Hattie Maxon
<br />166£ LICENSE NO.
<br />1454
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />Middle, Mallon Staff
<br />CITY I TOWN
<br />Gibbon
<br />14b. RELATIONS18P.TO DECEDENT,.
<br />SD9use
<br />*Sc. DATE (Mo:,Oa1 Yr•)
<br />December 7,2019
<br />17a FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)'
<br />$ tr AS Faiths Funeral Horne. 2929 S. Locust Street. Grand Island. Nebraska
<br />CrAUSE OF DEATH (See instruclIans and examples)
<br />1S PANT -1. Eater the chain of §vents• -diseases, injwies, or compncatlonsdhat directly casette the deem no NOT enter termtnat events such as cardiac arrest.
<br />+'aspiratory ewpftr or Y§mrfauler fibrillation without shoring the etiology. DO NOT ABBREVIATE. Enter only one cause ee a line. Add additional lines if necessary.
<br />+g¢ IMMEDIATE CAUSE:
<br />tCIMMEDIATE CAUSE a) Squamous Cell Rectal Cancer Localized
<br />a enema ,,r man: eon rewawty
<br />aagaetiaxariy liar eondhroes, 9 '. b)
<br />Uany leadl,rgtttth.causattsted::'
<br />art ane a
<br />A CONSEQUENCE OF:
<br />17b, Ztj1 Coda
<br />APPROXIMATE )71IAk
<br />ammo t1Stth
<br />3 Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />itlts(a6P0rInjury-that lntttete6;:;
<br />the eYents tesUalrig:.In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />++ 18. PART II. OTHER SIGNIFICANT CONDITIONS -Condition contributing to the death but not resulting in the underlying cause given in PART 1.
<br />ChroniCHyppxic Respiratory Failure, Dementia
<br />20 tF P ALE
<br />Hot.pttsgnant witNn past year
<br />.i�•
<br />0 Piiarhant at time of death'..
<br />Net opsnatrZ;but ptagnaef. wham 4Z days of death
<br />❑ Nat pnegaatd', Dat pregnat 4$ days to 1 year before death
<br />or,,vowo Bprpynatttvagteit a past year
<br />21a. MANNER OF Dy'H
<br />® Nahum. ❑ H6riCide
<br />❑ Accident ❑ Pending investigation
<br />❑ Saieide ❑ Couldnet be dabtpl n:s
<br />21b, iF. RtANSPORTAT10 i INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />can
<br />o Oker1speciN)
<br />19. WAS MEDICAL EXAMINER
<br />OR ODRONER cosi'At:7ER�
<br />❑ NMS NO
<br />210, WAS AN AUTOPSY P itMRt.?.
<br />Per yah ,...•
<br />21d. WERE AUTOPSY F AUAN.ABLM
<br />TO cotensTE CAUSE i7F OSAT '7
<br />❑ YES ❑ Ii{O
<br />,11 22a. DATE OF INJURY (Mo:, Day, Yr.)
<br />22'd INJURY ATW0RK?
<br />' ❑YES .DNO
<br />OF INJURY
<br />220. PLACE OF INJURY -At home, farm, street, factory,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />rn
<br />e 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO.
<br />eta (
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />8
<br />;bent 0410co V .i:ii(ma.,tiay, rr:)
<br />4ilbidaitiber2, 2019
<br />23b. DATE SIf1IED (Mo., Day, Yr,)
<br />December 3. 2019
<br />23c. TIME OF DEATH
<br />10:10 PM
<br />Sd. To the best of cry knowledge, death occurred at the time, date and place
<br />and due to the cause(e) stated (Signature end Title)
<br />•lyan'D Crouch. DO
<br />Olt? TO ACCC: USE I : NTRIBUTE TO THE DEATH?
<br />❑ YES El NO 0 PROBABLY 0 UNKNOWN
<br />0.pAtt0(mm Uono.,Vey;kCj
<br />FS99:0UNCED DEAD (Mo., DMI, Yr.)
<br />849. Ti7w##'Cir wEA.t`FI
<br />249. T Ili IAONOU(gti ECi
<br />Zee. On the basis of e>mm1feaon andfor bnwatytllen, inlay
<br />...... the thee, dab and place and due b the cause(s) visaed
<br />26a. HAS ORGAN. oR Ti.3Ua.DoNTIoN CONSIDERED?
<br />❑YES 2 N
<br />death scauntts et
<br />and Tape)
<br />fie. WAS C0NSENl6 tANTEO?
<br />Not Applicable N 26a leNQ ❑ YES a..t
<br />27. NAME, T1TLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Riled D. CIOUch, DQ, 800 N Alpha Street, Grand Island Nebraska 68803
<br />26a :REGM11/Akl':> SIGNATURE
<br />28b. DATE FILED BY IE.rOMORAR tM4
<br />December 10; 2,019
<br />1-I
<br />
|