|
<br />STATE OF NEBRASKA
<br />
<br />"
<br />
<br />',", ',~
<br />W.fiRN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAIi:rifAo/R H.-lIM..~. .NSERVICES, IT CERTIFIES
<br />1"- . THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB,R.Astbf:t?~A,.'jrfI4ENr'OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY......::.~0..:R.4... ",,'.. ..(-!...~f, .' ..~~lEf..~......'~.......'..'..'.'.'.'.:..........;.....:.:1.',.. ....'
<br /> ,
<br />
<br />DATE OF ISSUANCE ,~~.. .,....~
<br />
<br />NOV .17 2008 )IDJk~~Jif'~~I~i~~R
<br />
<br />"\,D1jf'ARTMENT OF HE~Lr.H XfNP
<br />'.'. Hr(p.tAN,?t:..R VICE$ , ':~' ~. c) _'
<br />\,fi ~1 ~;: "';.... t.......5~;~7 ":".c),,~,,,,:.,''''... \.:' "',,"~
<br />\ j. (IS<....::!.,':... ";.-,,,.
<br />~, I ' ~ '\ l .
<br />;;" . JU I' " - _,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FIN~Nd:.A['JOSlWPo~ -8 313 71
<br />CERTIFICATE OF DEATH ,"",. ""-' V
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />200901807
<br />
<br />
<br />1, DECEDENT'S-NAME
<br />
<br />(First,
<br />Kimberly
<br />
<br />Middle,
<br />Marie
<br />
<br />Last,
<br />Melnick
<br />
<br />Sulllx)
<br />
<br />2. SEX
<br />Female
<br />
<br />3. DATE OF OEATH (Mo" Day, Yr,)
<br />November ,4, 2008
<br />
<br />4, CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Grand Island, Nebraska.
<br />
<br />Sa, AGE-Last Birthday 5b, UNDER 1 YEAR
<br />(Yrs,) MOS, DAYS
<br />38
<br />
<br />5C, UNDER 1 DAY 5, DATE OF BIRTH (Mo" Day, Yr.)'
<br />HOURS MINS,
<br />
<br />July 7, 1970
<br />
<br />6a, PLACE OF DEATH
<br />
<br />J:l.QlifIlAL:
<br />
<br />Xl Inpati.nt
<br />
<br />QlliEB: a Nursing Home/LTC a Hospice Feclllty
<br />
<br />eb, FACILlTY.NAME (II not fhslltuHon; give ~traat aM numb.r)
<br />
<br />St. Francis Medical Center
<br />
<br />~
<br />
<br />a ER/Oulpatienl
<br />
<br />a Docad.nt's Home
<br />
<br />aiXl'.
<br />
<br />a Oth.r (Spocify)
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code I
<br />
<br />Gra.nd Island, 68803
<br />
<br />6d, COUNTY OF DEATH
<br />Hall
<br />
<br />Hall
<br />
<br />
<br />9a, RESIDENCE.STATE
<br />Nebraska
<br />
<br />9b, COUNTY
<br />
<br />9d, STREET AND NUM6ER 9f.ZIP CODE
<br />2!_~_ Ca.mpbell Ave. 68832
<br />10a, MARITAL STATUS AT TIME OF DEATH Jl! Married a N.v.r Marri.d 10b, NAME OF SPOUSE (First, Middl., Last, Sufllx) II wife, give maiden name,
<br />
<br />9g,INSIDE CITY LIMITS
<br />a YES ~ NO
<br />
<br />a Divorced a Unknown
<br />
<br />Steven Melnick
<br />
<br />1 I, FATHER'S-NAME (First,
<br />Larry
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S.NAME (First,
<br />Ma1;'y
<br />
<br />Middle,
<br />
<br />Mald.n Surneme)
<br />
<br />Wigstone_._
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />Opp...
<br />
<br />13, EVER IN U.S. ARMED FORCES? Give detes 01 service il yes, 14a,INFORMANT.NAME
<br />(Yos, no, or unk,) No Steven Melnick
<br />
<br />15, METHOD OF DISPOSITION
<br />
<br />a Burial
<br />
<br />o Donation
<br />
<br />
<br />16a EMB LMER-SIGdRE~~
<br />
<br />
<br />REMATORY OR OT~ LOCATION
<br />
<br />16b. LICENSE NO.
<br />_ut _l3:;' 8
<br />
<br />CITY I TOWN
<br />
<br />16c, DATE (Mo" Day, Yr,l
<br />
<br />November 10, 2008
<br />STATE
<br />
<br />I2iCremation CJ Entombmenl
<br />
<br />a Removal a Oth.r (Sp.cify)
<br />
<br />Westlawn Memorial Park Crematory,
<br />
<br />Grand Island, NE
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Straet, City or Town, Stat.)
<br />Apfel Funeral Home, 1123 West _Second,
<br />
<br />Grand Island, NE.
<br />
<br />
<br />, '
<br />
<br />
<br />PART I. Enter the chain of events--diseases, InJuries, or compllcationS--lhal directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest. or ventricular fibrillation without showing the .tiology, DO NOT AB6REVIATE. Enter only on. cause on a line, Add additicnslllnas if neco.sary,
<br />IMMEDIATE CAUSE:
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />ons.t to d.ath
<br />
<br />IMMEDfATE CAUSE (Final
<br />dlsea.e or condition resulting
<br />In cIGath)
<br />
<br />(a) A1~f)(tod::JJCt.1 L./'~e.-H&/L
<br />DUE TO, OR Is A CONSEQUENCE OF:
<br />
<br />
<br />9-.
<br />
<br />Sequentially list conditions, If
<br />any, leading to the ceuse listed
<br />online..
<br />Entertho UNDERLYING CAUSE
<br />(dl..... or Injury thallnltletad
<br />the events resulting in death)
<br />LASr
<br />
<br />(b) .$->.,)~l'tp __ ('F;--/'OA~V A~Jv
<br />DUETO,ORASACONSEOUENCEOF: ~ /
<br />
<br />~e~~___....._._
<br />
<br />I onset to death
<br />I
<br />I
<br />I
<br />I onset to death
<br />I
<br />I
<br />
<br />(cl
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(dl
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the d.ath but not resulting in the underlying caus. given In PART I,
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />CJ YES a NO
<br />
<br />20, IF FEMALE:
<br />liD Not pregnant within pest yoar
<br />a pr.gnanl at time 01 d.alh
<br />a Not pr.gnant, but pr.gnant within 42 days of death
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />_ 0_ UnJ<-"o~l'j!_Q!lllll<lul~l!h!!l!h. pa.lll'ae<,
<br />
<br />21a. MANNER OF DEATH
<br />1fJ Natural 0 Homicide
<br />
<br />21b, IFTRANSPORTATlON INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />a Accidenta P.nding Investigation
<br />a Sulcld. a Could not be determined
<br />
<br />o Passenger
<br />Q Pedest,lan
<br />a Other (Sp.cify)
<br />
<br />f( YES
<br />
<br />a NO
<br />
<br />a YES a NO
<br />
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />YE~ L! NO
<br />
<br />22a, DATE OF INJURY (Mo:, Day, Yr.)
<br />
<br />22b, TIME OF INJURY 22c. PLACE OF INJURY.At hom., farm, streel, feclory, ofllce building, construction olte, .tc, (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO,
<br />
<br />CITY/TOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />f'm
<br />
<br />",~1:;
<br />...Oz
<br />~_a:
<br />"'0
<br />31=;
<br />ct.'" iC ~
<br />~~~~
<br />1Jzji!
<br />~~ts
<br />O~
<br />00
<br />
<br />m
<br />
<br />24C, PRONOUNCED DEAD (Mo., Doy, Yr.) ~4d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basis of examination and/or investIgatIon, In my opinion death occurred at
<br />the lime, date and place and due to the cauo.(s),stat.d, (Signalure and Title) "
<br />
<br />~YES a NO a PROSABLY CJ UNKNOWN CJ NO
<br />-'27:N}..ME, TITLE AND ADDRESS OF CERTIFIER (pHYSICIAN, CORONER' PHYSICIAN OR COUNTY ATTORNEYI (Type or Print)
<br />Brant Luebbe M.D. 820 N. Al ha Ave.,
<br />
<br />2Ba, REGISTRAR'S SIGNATURE
<br />
<br />26b W~;.!GRtyEDZvve.s .
<br />Not Applicabl. if 25a Is NO ,.0 Y~~_~ NO
<br />
<br />NE 68803
<br />
<br />2eb, DATE FilED 6Y REGISTRAR (Mo., Day, Yr.)
<br />
<br />NOV 1 32008
<br />
|