|
531 s i1i . A " `I )Idadra0ltftt7J,dIII IZintteginmpli,:uk irIlllflfl%If 119rinuw il>)Id41,Y, 45,1
<br />r x4 i ......Y, )�tN eyl)I x rrnrrrpatt
<br />4a_STATE OF NEBRASKA
<br />,;.49esiattet y;z.1414rIlams3R9
<br />x s44t'4WPt3 a "+ar640t9NAlt o
<br />WHEN mis COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA,•IT CERT!PIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE, ORIGINAL RECORD ON FILE W1TH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />3/27/2023'
<br />LINCOLN, NEBRASKA
<br />rrryr/, ; tt 'a ,
<br />Ili) t »�I : ((tU la,,a,;
<br />r,r,r cp4 br0 � „�iy ,
<br />CF"40,jl6y ,trr15r7i)��$IIlr��(��(QS, ttU1'
<br />202306448
<br />SARAH BOHNENKAMP'
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DE,TH 16 09908
<br />1 DECEDENTS.NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Bay, Yr.) .r.
<br />Daniel Jerome !Hostler
<br />4. CITY AND STATE #1R TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY;NUMBER
<br />Z06,804679
<br />5a. AGE - LastBlrthday•
<br />(Yrs.)
<br />7.8:<:::.
<br />8b. FACILITY -NAME Et not Institution, give street and number)
<br />Wedgewood Care Center
<br />8c:;CITY OR TOWN OF bEATH (include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />ad.$TREETAiIDNUMBER
<br />2202 Plainer 81vd••
<br />9b. COUNTY
<br />Hall
<br />105.:MARITAL STATUS AT TIME OF DEATH l] Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER S►iIAME (Flfst Middle, Last, Suffix)
<br />Frank Hostler Sr
<br />13. EVER IN UE ARMEE>FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk) NO
<br />1S. METHOD OF DISPOSITION
<br />l Burial ❑ Donation
<br />la•CreMatiodt".Entombment
<br />❑ Rambval ❑Other (Spicily)
<br />5b.
<br />Male November 24,,2016
<br />UNDER 1 YEAR 6: DATE OF BIRTH(Mo., Day, Yr.)'
<br />July 21, 1938
<br />MOS.
<br />8a PLACE OF DEATH
<br />HOSPITAL ©';inpatient OTHER'I 1 Nursing Home/LTC
<br />0 ER/Outpatient 0 Decedent's Home r,
<br />0 DOA 0 Other (Specify)
<br />DAYS
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />'Mb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maic
<br />Sandra Armstrong
<br />14a. INFORMANT -NAME
<br />Sandra Hostler
<br />16a. EMBALMER -SIGNATURE
<br />Christopher J. Loecker
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a.;FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State):;,
<br />Apfei Funeral Home 1123 W. 2nd, Grand Island, Nebraska
<br />Sg Hope c TYt;IMIr8
<br />IRI vas CJ ;NO
<br />12.,MOTHER'SNAME (First, MIddle, Maiden Surname)
<br />Josephine', Placke
<br />16b. LICENSE NO.
<br />1421
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- diseases, Injuries, or compllcatlons.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 line. Add addhional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />lMMmwTgcAUa6 (Ental a) Metastatic Renal Cell Carcinoma
<br />'di see dr txxWlt tin r4avriini
<br />In deati4..
<br />Sequentially list Conditions, If
<br />any, leading to the cause Sated
<br />....._. alta
<br />lata.._ ..... ...._.__
<br />on knot.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EMetthe UNDEIR Ye4GCAUSt c)
<br />....eorInjury
<br />(disease Oti:l tfnigeteil
<br />Me wells revoking In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />14b. RELATIONSHIP TO DitceOENT.'
<br />Spouse
<br />I6c. DATE (M0,, Day, yr.)
<br />November 30,;:2016
<br />8TA1"E
<br />Nebraska
<br />..."7*.zwcociefo
<br />68801 ;
<br />APPROXIMATE INTERVAL
<br />onset t4death
<br />4 Years
<br />18. PARTE. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART 1
<br />Ischemic Head DROSSe, Diabetes Mellitus Type II r
<br />20. IF FEMALE:
<br />o Notpnlgnafllwlthlnpastyear
<br />❑ Preghald ato*. of rias*,
<br />❑ N Preeen n but otegaantwithin 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown It'pt'sgdentwatlin ik peat year
<br />22a, DATE OF INJURY (Mo Day, Yr.)
<br />22d. INJURY AT WORK?
<br />0 YES C) NO::
<br />21e. MANNER OF DEATH
<br />Natural ❑ Homic
<br />0 Acciditle
<br />ent ❑ Pend ngInvestigation
<br />0 suicide ❑ could not be determined'
<br />22b. TIME OF INJURY
<br />2180, IF: TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Q. Passenger
<br />0 Pedestrian.
<br />o Other (Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?;
<br />❑ YEs NO
<br />21e. WAS AN AUTOPSY,. PERFORM,,
<br />❑ YES ® 444.1F
<br />•
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES Q NO
<br />22c. PLACE Of INJURY -At home, farm, street, factory, office building, construction site,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LACATION'OF INJURY.;: STREET & NUMBER, APT.NO. CITY/TOWN.
<br />23a. DATE OFDEATH (Mo., Day, Yr.)
<br />November24, 2016
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />No/amber 29, 2016 08:12 PM
<br />To the lot army knowledge, death occurred at the time, date and place
<br />en due to the causes) stated. (Signature end Title)
<br />William Landis, MD
<br />25. DID TQBACCO USE CONTRIBUTE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />Sffeo(Fy):'
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b.
<br />ME OF DEATH;
<br />ZtP 000E
<br />24d. TIME PRONOUNCED DEAD,,,_.
<br />4e. On the Wads of examination andlor investigation, In my opinion death aaautrad.. :.•
<br />the time, date and place and due to the cause(s) stated. (Signature and.TMO)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES Ea NO
<br />27. NAME, TITLEAND ADDRESS OF CERTIFIER (Type or Print
<br />William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska,' 68803?
<br />28a. REGISTRAR'S SIGNATURE C
<br />r
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES
<br />❑ NQ>
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 30, 2016
<br />00
<br />
|