|
....................
<br />..;ii(Iff,7//iritg.4t0I(Itli,flIRI.I4.•448. )7/33II.itVi,,;,'AIIII(Ptigil(3%iflik(I(If/.111((tiffb.t.,•,o...,•))))tott(t/,•oL,...,..toz:I.Y,0((i.,-,,
<br />............................................................. • • •
<br />STATE OF NEBRASKA
<br />,
<br />„ .,„„ ....... .
<br />...."..4,11Sa:-.!:COi:IY CARRIES THE RAISED:"... :SEALOF TFIE ....STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />0 0 ,
<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 />• • Is,,St)AFECE
<br />• 9/19/2017
<br />UM°4A1'114BRAPICA'. STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />:•••••• STANLEY S. PER
<br />2 2 rio:6
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DEDEDENTI-NAME (Fir*, Nflddle, LastSuffix)
<br />Nancy Sue Jack
<br />.4,,DITY..AND;sTATEoR TEFRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />. •
<br />FrankBit:Nebraska
<br />•• • 7. SOCIAL SECURITY.•NUMBER
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr)
<br />September 90, 2017
<br />04..,111,!ppR 1...YEAR
<br />MOS. . ....DAYS
<br />8a. PLACE OF DEATH
<br />gite.streetand number)
<br />• • • •
<br />Goc$a.niathafl .. iety-Wood River
<br />CflY OR !OWN OF DEATh
<br />• ..- -•::•• • ••
<br />(1001,00(.1,2it,,icode)9a „:,.... •
<br />Woad..River. 68883
<br />••••1',
<br />........ .RaSDENE.STAT
<br />••• ••••• • • ••• •••• • .:.:.... ..,..:..
<br />•"••". • • •••.• • -----.••••• •-• ••• • • •• • .
<br />• ••• • • • •••••••• • • •••• • • •.....•••••••••-• • ••• ....... .
<br />Hall
<br />9d. STREET AND NUMBER
<br />304 E 6th Street
<br />10a6tarri
<br />mARatT:STATIJ AT TIME OF DEATH g] Married 0 Never Married
<br />separated 0 Widowed D Divorced 0 Unknown
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />6. DATE OplitIFr7Nit.A024:..
<br />• .•,.• • ••••••„•• • •
<br />November 12,.1937 .
<br />OTHER ria Nursing HomeA.TC Hospice Facffity
<br />Other (Specify)
<br />8d. COUNTY OF DEATH•
<br />Hall• •
<br />CITY ORTOWN.
<br />WOCKI River
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />9g. MIL* ClitY OW*
<br />ffj YES 0 NO
<br />.19b. NAME OF:SPOUSILIFIcIA::...., Middle, Last, Suffix) If wife, giveffictidettnctmei,„...
<br />eary Joe
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Mervin Deck
<br />13. EVER INUS. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No or Unk.)
<br />.21
<br />15. METHOD P.:4F DISPOSITION
<br />Burial Donation
<br />Cremation Eritombmerit
<br />14a. INFORMANT -NAME
<br />Gan/ Joe Jack
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER1I-NAME (First. MIdellta, Maiden Surname)
<br />Mary Robinson
<br />.16b...UCENSE NO.
<br />......
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Re""fat°ther(8"c fY) Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL IF.XME NAME AND MA UNG ADDRESS (Street, City or TownState)
<br />Abfel 'Funeral H.e. 1123 W. 2nd, Grand Island. Nebraska
<br />143/,'RELATIONSISP.TODEqEDENT:
<br />• SPouse,„.
<br />16e..DATE
<br />September kf2.,. 2017
<br />• STATE
<br />• :Nebilllakt.
<br />•-• 88&1 • • • •
<br />CAUSE OF DEATH (See Instrtict(ons and examPles)
<br />PAR:TI. Etter thi;•idiate Of.ei:o-nts.- -diseases, 'Mud.% or complications -that directly caused the.deatIlpotiQY.enleetenitiotal eVerits such as cardiac arrest. APPROMO4ATONTERi*.
<br />mspIrat0,yarrei* or eat,4cLi1Ir tisrittation without showing the etiology. DO NOT ABSREV*AIE Enlet only:.Orodettre one line Add additional lines If necessary.
<br />IMMEDIATECAUSE onset tli!trt
<br />moscutiAr6 CAUSE Wing . a) Alzheimers ; 9n Host:Iste
<br />.
<br />distiarie or condition
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />ieetreatrialliiatcOnditiOds, u b) Diabetes Type 11
<br />any, Owning to tie cats. listed
<br />Qn
<br />'Inc a' DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Chronic Kidney Disease
<br />Enter the UNDERLYING CAUSE
<br />Obviate or lieury that initiated
<br />ants reOnitinti "I*6) DUE TO, OR AS A CONSEQUENCE OF:
<br />.
<br />d),Hypertension
<br />; onset to death
<br />18. PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />0 Not pregnariteithirtplud Year
<br />' n Pregnantet time Of death'
<br />C.) "
<br />.0 Ntilliatfillarailt lirattliaA vAthIn 42 days Of death
<br />Not Inelinnift,becetneriaitt13 nava to 1 year before death
<br />-
<br />0 ,ilil0000ti Otrtegnant:Voithlit the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF: DEATH
<br />511 Natural 0 leankide
<br />0 Accident 0 Pending investigation
<br />o Suicide Cypouldrilit beetetenntnect0;:
<br />211),...1f1FANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />rj Pedestrian
<br />Other(S...fry)
<br />19. WAS MEDICAL INER
<br />OR CORONER ACTED?
<br />21c. WAS AN AUTOPSVOORPOAMEW,!:'
<br />21d. WERE AUTOPSV.FINDINGS AVAILABLE
<br />TO COMPLETtbAUSZOMMATMM:
<br />OYES ONQ
<br />....
<br />27.d.....:1kuuRVATtiVpItKI0vs ONOT
<br />"••••••••••",'
<br />22b. TIME OF INJURY
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, constructlon site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />.33a. DATE OF. OBATH (Mo., Day, Yr.)
<br />altIlatiit,10, 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Seotmber11,2017 11:1 PM
<br />CITY/TOWN
<br />and d to the cau
<br />IADChdViethMD
<br />25. 'T).10..rooi1/4000 uga......pplifraisuTs TO THE DEATH?
<br />.......
<br />CI'VES El NO " D PROBABLY U UNKNOWN
<br />STATE
<br />p.a7a,s,IGNED (Mo., Day, Yr.)
<br />24b. TIME OPDENTH •
<br />.84c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />240. On *0. 00919 of examination andlor inveStigation, in my opinion death °caused at
<br />the time, date and place and due to the cause(s) stated. Pluralism a001111.)
<br />2 , „
<br />....... ......,
<br />28a. HAS ORGAN OR TISSUE DOICATION SEEN CONSIDERED? 261). WAS
<br />YES _ NO Not Applicable if 26a le NO CIES ',ONO
<br />27. NAME, TITLE AND ADDRESS QF CERTIFIER (Type or Print'
<br />Chad Vieth, MD, 2116 W Faidley It400, Box 9802, Grand Island Nebraska,688Q
<br />28CREGISTRARSiSIONAttIRE:q.',:hT
<br />28b. DATE FILED BY-115011ifrAfti*!j'Yiligi: .1g
<br />September 13, 2017 )if'81: .•:.,.!::'::0V
<br />
|