|
Ai.. IR,111iMP n„*)4/449n„mmA(iiltillt/(IE) „ ,,, Aft)J,1;1 o
<br />U
<br />a
<br />:WAIN
<br />iitlllN110DJ"
<br />!r1✓i1 �1
<br />-..kirrlli111Nt�� ,: rrn r„,t,
<br />•
<br />WHEN ! THIS <"COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BEAA A TRUE COPY OF THE ORIGINAL RECORD
<br />Qpi FILE WITH .:THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE,' WHICH IS THE LEGAL DEPOSITARY FOR VITAL„REC0RDS
<br />'� lnnH,1
<br />?4(ililllltllii .
<br />DA. TE OFISSUANCE
<br />113112020
<br />LINCOLN, NEBRASKA
<br />.. RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA: .DE PAt2llfitENT OF; HEALTH AND HUMAN SERVICES
<br />CERTIFICATE IAF DEATt
<br />1. DECEDENDS NAME (First, Middle, Last, Suffix)
<br />Thomas Melvin Atkins Sr
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Affiance, Nebraska
<br />1. SOCIAL SECURITY NUMBER
<br />508-54-3284
<br />5a AGE.: Last Birthday
<br />(Yet)
<br />80. FACILITY NAME (If not Institution, give street and number)
<br />Good Sam. Society -Hastings Village, Perkins Pay.
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Hastings 68901
<br />9a.'REEIOENCE $TATE
<br />Nebraska
<br />9d. STREET'AND NUMB
<br />1020 E D St
<br />9b. COUNTY
<br />Adams
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />.MOS. •
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />.ERfOutpatient
<br />0 DOA
<br />DAYS
<br />CITY.OR1"OINNt: •
<br />•
<br />l�iastings
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH'(Mo., Day, Ytr,?
<br />January 13, 2020
<br />6. DATE OF BIRTH (filet„ Clay, Yr).;,
<br />August 3, 194
<br />OTHER I1 Nursing Home/LT4
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Adams
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68901
<br />Hospice Facility
<br />INS(DE CITY LIMIT$
<br />I1 YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Marrieq, but; separated,;: 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHERS•NAME (First, Middle, Last, Suffix),
<br />Melvin Fay Atkins
<br />19b. NAME OF:S POUSE(First, .:::;Middle, Last, Suffix) If wife, give maiden name;
<br />Linda .Atkins •
<br />12. MOTHERS -NAME (First, Middte, Maiden Surname)
<br />JoAnn Margaret Evans
<br />13, EVER:.IN U.S.: ARMED FORCES? Give dates of service if Yes.
<br />1Yes4No t1rUnk.)Ye$ 01/02/1966-11/09/1971
<br />14a. INFORMANT -NAME
<br />Linda Atkins;
<br />14b. RELATIONSHIP TO DECEDENT.,
<br />Spouse
<br />15 MirTH00 OF.DISeosrnoN
<br />•
<br />® BUHaf ❑ Donation
<br />0 Cremation 0 Entombment
<br />ReMOyal :( Other::(Epeclfy).:
<br />18a. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />Mt -LICENSE NO.
<br />1411
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />17a Fl f4ERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island. Nebraska
<br />18c. DATE (Mo Day;? 'r.) ,..
<br />January 14, 2020
<br />• STATE
<br />Neb asks"
<br />1Tb Zip Code
<br />68803
<br />CAUSE OF D ATI -I (See instructions.. and examples)
<br />tE, PART L inter ebb d)tain o:{eve nit -.diseases, injuries, or compllcatlonsdhat directly caused the heath O0 NOTentOte mj_
<br />respiratery 4rreSt or vernncelar flbngation without showing the etiology. 00 NOT ABBREVIATE Ertter only'gne cerise On:a
<br />i.' IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) ischemic Heart Disease
<br />disease or condition resulting
<br />inslaaen)
<br />Sequantiany (lat condblona,11
<br />any, (ea ling:: tethe;catna;tteted
<br />Enter the UNOERLYINO CAUSE
<br />IdNeesegr3itjury(.fiatdnh(at0d s,<
<br />tM events resorting 1n death(
<br />LAST ..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Diabetes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Agent Orange Exposure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />eittents such as cardiac arrest,
<br />gyre. Add addmonsl lines if necessary.
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART
<br />2i , iF ftEMALE
<br />❑
<br />Not pregnant within peat year
<br />❑ Not r dt at time of death
<br />Nat pregnant but pregn4M Within 42 days of death
<br />❑ Nat pregnant bpf pretjnam 43. days to 1 year before death
<br />❑ un&mtwdif Areinaittwnttxnthe past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />122d INJURY AT WORK?
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could dirt be dendinited
<br />22b. TIME OF INJURY
<br />21btF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />D Pedestrian
<br />Otherlgpecify)
<br />APPROXdeATEINTERVAL
<br />oneetta Beam:
<br />Years .
<br />Years
<br />onset to death
<br />Years;:.
<br />1. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ENO
<br />21c. WAS, .N AUTOPSY 1ERFORMPD? .
<br />❑ YES E ,NO
<br />21d. WERE AUTOPSY:FINDittf3$ AVAILABLE
<br />TO COMPLETE CAUSE QF DEATH?
<br />❑ YEs ❑ HQ
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />❑YE$ (:);NO
<br />t"
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />*.DATE OF DEATH (Mo., Day, Yr.)
<br />Jaittsry 13,!2020
<br />Ix mot SIGNED (Mo., Day, Yr.)
<br />January 15.2020
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />12:44 PM
<br />3d. To the beat of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Brett A Maichlw, MD
<br />STATE
<br />24a DAPS $1GNED (Mo., Day, Yr.)
<br />24c', PRONOUNCED DEAD (Mo., Day, Yr.)
<br />S
<br />NY)
<br />ZIP CODE
<br />24d. TIME PRONOUN..ED
<br />24e. On the basis of examination andior investigation, in my *pinion deeat occurred at
<br />the time, date and place and due to the cause(e) stated. (Signature and Title)
<br />25 DID 'TOBACCO 'OSE CONTRIBUTE TO THE DEATH? N;B....
<br />❑ YES Q NO QPROBABLY ;® UNKNOWN
<br />27. NAME, TITLE AND-ADDRESSOF CERTIFIER (Type or Print)
<br />Break Maiohow;:MO, 223 East 14th St, #100, Hastings, Nebraska, 68901
<br />28aaeOistIO
<br />SIGNATURE
<br />28a. HAS ORGAN OR TISSUE:DONA'RO
<br />0 YES ENO
<br />EE
<br />ONSIDERED?
<br />26b. WAS CONSENT GRAN
<br />Not Applicable If 28a is NO
<br />� YEs
<br />NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day; Yr )
<br />January 24, 2020
<br />
|