|
N00,001
<br />t}V984 aeta4+ri+eliii�i �1
<br />s�e�tt4�
<br />•t98stediH)):iliaaat•sk‘aiNolio11) II$i
<br />a S}„1jQ$Syya(r sae
<br />�$��rlll�l�l�lllg�l�sr4r3tr�tr 1�91t1�,tl)�(/i(((,
<br />Muaatl,. ,,,� 5s!117}t1111(ta��r
<br />�tatt�i�rt'aat�
<br />? kfil1}klWtaatt .;'
<br />EA( HIS COf YCARRIES THE RA/SED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />A TRUE COPY OF THE ORIGINAL RECORD, ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />AN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE CTF ISSUANCE
<br />11/21/2022;
<br />-1NCOLN,, NEBRASIC4
<br />202300382
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />8
<br />). DECEDENT'$ NAME jFjrst, Middle, Last, Suffix)
<br />l.Jakeb
<br />CERTIFICATE OF DEATH
<br />4. GLTYAND STATE OR TERRITORY; OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />T. SOCIAL Sept1RITY N(iMBER
<br />506-66-9882
<br />5a:>AGE - Last Birthday
<br />(Yrs.)
<br />8b. FAC+LUTY+NAME (1€not Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. GITYOR TOWN OF MEATH (Include Zip Code)
<br />Grand Island 88803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />3d STREET AND NUMBER
<br />2508 Riverside Dr.
<br />70
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OTDEATH
<br />HOSPITAL 11 itlpetient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9b. COUNTY
<br />Hall
<br />10a MARITAL $TAUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S NAME (First, Middle, Last, Suffix)
<br />Henry Jakob
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEAT ...(1,40 Day ; .: Y
<br />October 29.:2Q22
<br />6. DATE OF BIRTHIMo., Day, yr.)
<br />December 10.;1;951 .
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />;YES ❑ ;NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Dee Garcia
<br />13.,EVER IN tJ. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or'Unk) No
<br />15.'METHOD OF DISPOSITION
<br />EI Bur(at ❑ Donetton
<br />Cremath n ❑Entombment
<br />�] R�moval< ❑ ONter (Specify).
<br />14a. INFORMANT -NAME
<br />Dee Jakob
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />12 MOTHER'S. -NAME (First, Middle, Maiden Surftame)
<br />North Ewoldt
<br />16b. LICENSE NO.
<br />1092
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />14b. RELATIONSHIP TdDEEEbBaT:'
<br />Spouse
<br />18c.DATE (M0.,Dty,.Yr) ..
<br />November 4; 2022
<br />BTATI#
<br />Nebraska
<br />Ate. m <:
<br />88801.....
<br />CAUSE OF DEATH (See l latructloris and examples)
<br />18. PART 1. Enter the chain of events -.diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilse. Add additional lines M necessary.
<br />IMMEDIATE CAUSE:
<br />94M IAi'ECAti8E(Ftnr4 <, a) cardiopulmonary arrest
<br />daitose ar condition rasultuig
<br />in
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />oq
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />IN head trauma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EnterthotINOSRLYINGCAUSE c)
<br />(di:seaiti or injury that hdtiated
<br />the everts res Ring in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 )?ART II.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />morbid obesity, congestive heart failure
<br />IF FEMALE:;
<br />❑:
<br />t
<br />Not pregnaslt whhkt pas' 'ear
<br />. Pregnant atlale at death:
<br />❑ Nat pragriel but preglisnt within 42 rays of death
<br />Not pregnant, but pregnant 43 days tot year before death
<br />UnknownR.pregnant whhin the past year
<br />22a.DATE OF INJURY (Ma:, Day, Yr.),
<br />October *2022
<br />22ct.INJURYAT WORK?
<br />❑vas,._®Na
<br />21a. MANNER OF DEATH
<br />❑ Natural ❑ Hotnkide
<br />® Accident ❑ Pending investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />10:45 AM
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Drltier/Operator
<br />.❑ Passenger
<br />❑Pedestrian
<br />❑ Other (Specify)
<br />APPROXIMATE INTERVAL
<br />onse}to.death
<br />15 Minutes
<br />onset to death
<br />15 Minutes
<br />onset
<br />onset to death
<br />19. WAS MORAL EXAMINEit:
<br />ORCORONERCONTA ED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMBOT
<br />❑ YES N0
<br />21d. WERE AUTOPSY F(WDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO ,.
<br />22e. PACE OF INJURY -At home, farm, street, factory, office building, construction site, tits
<br />Nursing Home
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />patient fell forward off of the toilet while on the 6th floor of St. Francis Medical Center in Grand Island, NE
<br />22 . LOCATION OF INJURY- STREET & NUMBER, APT.NO.
<br />0 Yv AVE:. Grand Island
<br />23e. DATE OPOEATH (Mo., Day, Yr.)
<br />October 29, 2022
<br />2313, DATE SIGNED (Mo., Day, Yr.)
<br />( 9Ve111ber 16.2022
<br />�aeti Tatha bootoftt)irknowledge, death
<br />DID TOBAi
<br />Yrs .:
<br />crrtrrOVWri
<br />TIME OF DEATH
<br />11:15 AM
<br />occurred
<br />at the time, date and place
<br />use(s) stated. (signature and Title)
<br />r, MD
<br />USE CONTRIBUTE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />STATE
<br />Nebraska
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />(SP- Sr
<br />QIP CODE' '<:
<br />68813
<br />24d. TIME PRONOUNCED
<br />24e. pn the bdtIs of examination and/or Investigation, In my opinion deat)t xiaadrreti5)
<br />Uteilrlta, date and place and due to the cause(s) stated.( Signaturean{littie)
<br />O 26a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED?
<br />NO ❑
<br />0 YES NO
<br />I40 ADDRESS OF CERTIFIER (Typeibr Print
<br />t1rr, MD 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />NATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO YfrS
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 18, 2022
<br />
|