|
t
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL- RECOFa -QN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERV ICES SYSTEM, VITAL STATII7CS- 5Ef;YlQ19[F/ICM IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />MAY ` 0 % () O - - TANLEY S. COOPER
<br />LINCOLN, NEBRASKA 200506833 HEALTH AND HUMAN.BERV►CES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE--AND StOPORT 0557,)
<br />_.._ CERTIFICATE OF DEATH U5 5
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3, DATE OF DEATH (Mo., Day, Yr.)
<br />Lola Dorothy Female
<br />..Margaret. Stecker ALar11 2620.0.5...
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 51b. UNDER i YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) HOURS MINS.
<br />Otoe County, Nebraska 83 MOS. DAYS January 31, 1922
<br />7. SOCIAL SECURITY NUMBER
<br />508 -22 -4330
<br />8b. FACILITY-NAME (If not Institution, give street and number)
<br />Wedgewood Care Center
<br />Be. PLACE OF DEATH
<br />HOSPITg4: ❑ Inpatient OTHER ]� Nursing Home /LTC ❑ Hospice Facility
<br />❑ ER /Outpatient J Decedent's Home
<br />_..... ❑ DON ❑ Other
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Tsland, NF 68803 Hall
<br />9a. RESIDENCE -STATE 9b. COUNTY 9c, CITY OR TOWN
<br />Island
<br />Nebraska Hall _ Grand Tsla � 1_68.80.1----- -..__ 105 F... 2nd St. ------ ��SE -S YLIMITS
<br />YES ❑ NO
<br />9d. STREETAND NUMBER 98. 9 . Bg.
<br />10a. MARITAL STATUS AT TIME OF DEATH 3i Married ❑ Never Married I lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Les S t e cke r
<br />11. FATHER'S -NAME (First,
<br />Middle,
<br />Last, Suffix)
<br />12. MOTHER'S-NAME (First, Middle,
<br />Maiden Surname)
<br />Henry
<br />Burr
<br />Emma
<br />Keller
<br />13, EVER IN U.S. ARMED FORCES? Give
<br />dates of service if yes.
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes,no,orunk.) No
<br />Les Stecker
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />_ ,....
<br />i6a. HER- 1Gf ATU
<br />---- --.,... ,_......- - - ----
<br />.,�
<br />- -- - - - - -.. ....
<br />16b. LICENSE NO.
<br />..._......, _ ................ .... .... ._ ... ........
<br />16C. DATE (Mo. Day, Yr. )
<br />LX13urial U Donation
<br />fir% eiV
<br />April 30, 2005
<br />❑Cremation ❑Entombment
<br />16d. CEMETERY, CR MATORY
<br />OR OTHER LOCATIO
<br />CITY /TOWN
<br />STATE
<br />Westlawn
<br />Cemetery
<br />Grand Island
<br />Nebraska
<br />C3 Removal ❑ Other (Specify)
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street,'City or Town, State)
<br />�2 176. Zip Coda
<br />11 Faiths Funeral Home 929 S. Locust St., Grand Island,NE 68801
<br />18. PART I. Enter the chin tiff v -enisdiseases, injuries, or compllcations that direct:y caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, orventricular fibrillation without showing the evology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />I
<br />C t
<br />IMMEDIATE CAUSE (Final (a) C. G-a` -
<br />L t b� ✓� AQa�--- r-�"�-
<br />disease or condition resulting DUE TO, OR AS A CONSEOUEN (t OF: I onset to death
<br />indeath)
<br />Sequentially list conditions, If (b) c V
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onsettodeath
<br />on line a.
<br />Enterthe UNDERLYING CAUSE
<br />(disease or Injury that Initiated (c) I
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: 1 ousel to death
<br />LIST
<br />(� I
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS- Condhlons contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />U YES 'A NO
<br />20. IF,FEMALE: 21a. MANNER OF DEATH 21 b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />&I /N LW
<br />ot pregnant within past year iPatural ❑ Homicide ❑Driver /Operator
<br />❑ Pregnant at time of death 11 Accident[] Pending Investigation ❑ Passenger El YE5 ly10
<br />❑ Not pregnant, but pregnant within 42 days of death ❑Suicide ❑ Could not be determined C3 Pedestrian 21d WERE AUTOPSY FINDINGS AVAILABLE TO
<br />❑ Other (Specify) El Not pregnant, but pregnant 43 days to 1 year before death COMPLETE CAUSE OF DEATH?
<br />U Unknown If pregnant within the past year _ Q YES U NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />224 TIME OF INJURY 22c PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK? 1 22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />221. LOCATION OF INJURY- STREET & NUMBER, APT. NO. CITY/TOWN
<br />STATE ZIP CODE
<br />23a, DATE OF DEATH (Me., Day, Yr.) C 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH
<br />s April 26, 2005 � ¢ m
<br />- _... -
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c ]4ME F DEATH i
<br />
|