|
1
<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 RECORD O*mE WITH m.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI�ECTIO - -WIMN IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br />Ar
<br />DATE OF ISSUANCE
<br />AUG 0 9 2005 C Q �a r��ootR
<br />LINCOLN, NEBRASKA 200 5 O 8 O 3 G H A� tT
<br />,i1LH(:B-
<br />STATE OF NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANF7SUPPOST
<br />-- CERTIFICATE OF DEATH 08675
<br />1, DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3, DATE OF DEATH (Mo., Day, Yr,)
<br />Loraine Helen Seim Female July 31, 2005
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH I 5a. AGE -Last Birthday 5b, UNDER 1 YEAR 5c. UNDER i DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Palmer, Nebraska (Yrs.) 82 MOS. I DAYS HOURS I MINIS. February 19,192'
<br />7. SOCIAL SECURITY NUMBER
<br />508 -12 -0348
<br />6b. FACILITY,NAME (If not Institution, give street and number)
<br />Lakeview Nursing Home
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient OTyEg: )D Nursing Home /LTC U Hospice Facility
<br />❑ ER /Oulpstlent ❑ Decedent's Home
<br />L) D04 ❑ Other (Speclly)_.......
<br />go. CITY OR TOWN OF DEATH (Include Zip Code) Ad. COUNTY OF DEATH
<br />Grand Island 68801 Hall
<br />9a. RESIDENCE•STATE 9b. COUNTY go. CITY OR TOWN
<br />Nebraska Hall _Grand Island
<br />9d. S TREET AND NUMBER go. APT. ND 9f. ZIP CODE
<br />1.03 E. 16th St-. 68801
<br />10a. MARITAL STATUS AT TIME OF DEATH 1 Married ❑ Never Married 10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, give maiden name.
<br />❑ Married, but separated U Widowed ❑ Divorced ❑ Unknown Harold Seim
<br />9g. INSIDE CITY LIMITS
<br />X3 YES ❑ NO
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />Gerhardt Renken Wilhelmina Luebke
<br />13. EVER IN U.S. ARMED FORCES? Give dates of se=yes. . INFORMANT -NAME 14b. 'R
<br />ELATIONSHIP TO DECEDENT
<br />(Yes, no, or unk) N 0 Harold Seim Husband
<br />IS. METHOD OF DISPOSITION 16a. B MER- 51GNATU E n • 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr, )
<br />(13urial ❑ Donation i / 1071 August 4, 2005
<br />❑ Cremation U Entombment 1fii�EMETERY, CREMATORY OR OTHER LOCATION ... J CITY/TOWN STATE
<br />❑Removal U Other (Specify) Westlawn Mem, Park Cemetery Grand Island, Nebraska
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Slate) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust St-Grand Island. N8 68801
<br />18. PART I. Enter the chain of eYear-- diseases, Injuries, or complicatlons- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest i APPROXIMATE INTERVAL
<br />' I
<br />respiratory arrest, or venitioular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. I
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE
<br />ATE GAUSE (Float (a) �..'�....,� ' �A,P „4..1: �„r., n • ��a-: ^... c7..,*r....;•...c..� ...1
<br />disease or condition resulting DUE TO, OR AS A CONSEQUEN A OF: I onset to death
<br />In death)
<br />Sequentially list conditions, It
<br />any, leading to the cause listed
<br />on line a.
<br />Enterthe UNDERLYING CAUSE
<br />(disease or Injury that initiated
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(c)
<br />I
<br />I onsetto death
<br />I
<br />I
<br />the events resulting In death)
<br />LAST DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />I
<br />(� I
<br />18. PART II OTHER SIGNIFICANT CONDITIONS ondlllons( contributing to the death but not resulting in the underlying cause given in PART 1, 19. WAS MEDICAL EXAMINER
<br />,1`; OR CORONER CONTACTED?
<br />v �;-l.r"., ..,y...�iLP...P.,� .�C vC` \4 L.L.(, r.., ❑ YES ❑ NO
<br />20, IF FEMALE: 21a. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />Not pregnant within past year _9( atural Ll Homicide ❑Driver /Operator
<br />El Pregnant at time of death ❑Accident❑ Pending Investigation
<br />❑Passenger
<br />❑YESNO
<br />El Not pregnant, but pregnant within 42 days of death ❑Suicide ❑ ❑ Pedestrian Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />❑ Not pregnant, but pregnant 43 days to I year before death ❑ Other (Specify)
<br />COMPLETE CAUSE OF DEATH?
<br />❑ Unknown If pregnant within the past year ❑ YES ❑ No
<br />22a. DATE OF INJURY (Mo , Day, Yr) 22b. TIME OF INJURY 22c. PLACE OF INJURY -AI home, farm, street, factory, office building, construction site, etc. (Specify)
<br />......- -- - - -..... m
<br />22d. INJURY ATWORK7 I 22e. DESCRIBE How INJURY OCCURRED
<br />C.) YES ❑ NO
<br />22f. LOCATION OF INJURY- STREET & NUMBER, APT. N0,
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />A
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />July 31 2005
<br />x
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />O U
<br />2
<br />six
<br />m
<br />0
<br />,1a
<br />_-
<br />tx
<br />_..__..
<br />.. ......._
<br />to r
<br />( ., ay, Yr,)__
<br />23b. DATE SiGNE Mo
<br />23c. TIME OF DEATH.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />M
<br />E z
<br />I
<br />1:39 P.m
<br />„a=
<br />m
<br />.�
<br />23d. To the best of my lowledge, death occurred at the time, date and place
<br />upl O
<br />24e. On the be of examination and /or investigation, in my opinion death occurred at
<br />O
<br />and dun to the cause(s) slated. (Signature and Title) '1'
<br />o p
<br />the time, date and place and due to the cause(s) stated. (Signature and Title )
<br />I
<br />w
<br />O U
<br />2
<br />26. DID TOBACCO USE CONTRIBUTE TO TH E DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />U YES_ ,NO C3 PROBABLY [J UNKNOWN _ ID YES �F,l NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO U YES U NO
<br />,1a
<br />a
<br />°,
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER
<br />illiam J. Landis
<br />( PHYSICIAN, CORONER'S
<br />M.b.
<br />PHYSICIAN OR COUNTY ATTORNEY) (Typeor Print)
<br />2444 W. F idle Ave. Grand Island NE 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />,(
<br />�J r
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />AUG - 0 2005
<br />
|