|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H,
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THEN
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY
<br />DATE OF ISSUANCE
<br />07/15/2014
<br />202404985
<br />Y S. COOPER
<br />kyTANT STATE RE(
<br />ARtMENT OF H
<br />CES, IT CERTIFIES
<br />ALTH AND
<br />AtaAASERVICES 2 3•�
<br />STATE OF NEBRASKACERTIFICATE OF DEATH HUMAN c f�Fo ac-ep14 01391
<br />LINCOLN, NEBRASKA
<br />To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Therese Alnanda Muchow
<br />2.44'.'1 , U 7' ,
<br />Female I. t ,t"
<br />3. DA F6VVDipti'H.pao., Day, Yr.)
<br />f !Fbuild KAarcfi 23, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY"
<br />- t DA'TM'Oit BIRTH (Mo., Day, Yr.)
<br />Sigourney, Iowa
<br />(Yrs.)
<br />87
<br />MOS.
<br />DAYS
<br />HOUR&
<br />MINS.
<br />June 11, 1926
<br />7. SOCIAL SECURITY NUMBER
<br />506-28-1900
<br />8a. PLACE OF DEATH
<br />HOSPITAI. Q Inpatient OTHER 0 Nursing Hom&ILTC Q Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />704 West 14th Street
<br />Q ER/outpatient ® Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />704 West 14th Street
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />[If YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated ® Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Marvin L Muchow
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William J Bermes
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Elizabeth M Biede
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Willliam Muchow
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />IXI Burial 0 Donation
<br />18a. EMBALMER -SIGNATURE
<br />Tracey Dietz
<br />18b. LICENSE NO.
<br />1328
<br />18c. DATE (Mo., Day, Yr.)
<br />March 28, 2014
<br />❑ Cremation Li Entombment
<br />Q Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />To be completed by: CERTIFIER
<br />10. PART I. Enter the chain of events --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac awast, I APPROXIMATE INTERVAL
<br />'aspiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if neesasary. t
<br />IMMEDIATE CAUSE: li onset to death
<br />IMMEDIATE CAUSE (Final a) Myelodysplastic Cancer I Gradual
<br />disease or condition resulting I
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />Sequentially list conditions, I b) I
<br />any, leading to the cause listed I
<br />I
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: ' onset to death
<br />Enter the UNDERLYING CAUSE C) e
<br />f
<br />(disease or injury that Initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: t onset to death
<br />LAST CO I
<br />f
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Multiple Myeloma Cancer
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />IXI YES ❑ NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />Q Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural Q Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ®NO
<br />❑SuicNot pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 47 days to 1 year before death
<br />Unknown if pregnant within the past year
<br />0 Q
<br />ideCould not be determined
<br />0 0
<br />0 Pedestrian
<br />Q Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specific)
<br />22d. INJURY AT WORK?
<br />AYES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />B
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />.t
<br />I
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />March 25, 2014
<br />24b. TIME OF DEATH
<br />Approx. 02:00 AM
<br />z
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />1 4 $
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />March 23, 2014
<br />24d. TIME PRONOUNCED DEAD
<br />07:46 AM
<br />l)
<br />8
<br />22d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(*) stated. (Signature and Title)
<br />,i i
<br />E o
<br />8 tt
<br />24e. On the basis of examination and/or investigation, in my opinion death ocaerred at
<br />the time, date and place and due to the cause(s) stated. (Signature and TIN*)
<br />Martin Klein, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 0 NO
<br />28b. WA8 CONSENT GRANTED?
<br />Not Applicable If 29a is NO Q YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Martin Klein, Hall Deputy County Attorney, 231
<br />S. Locust, P.O. B and Island, Nebraska, 68802
<br />r
<br />28a. REGISTRAR'S SIGNATURE A. i�,
<br />(�J�
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 25, 2014
<br />
|