|
STATE QF NEBRASKA
<br />r WHFfN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA
<br />HUMAN SERVICES, VITAL RECORDS OFFICE WHICH IS THE LEGAL DEPOSITORY FOR VIT~tL
<br />i
<br />DATE OF ISSUANCE
<br />09/01 /2009
<br />LINCOLN, NEBRASKA
<br />ANCktJillb,4/1r~SERVICES, IT CERTIFIES
<br />©~~~IR;TIµT OF:.HEALTM AND
<br />RE+~bDS..'''
<br />COOPER
<br />r" ~,~"R~~I RAK _.
<br />N1~F'H'C~IL~'~ ND: - .
<br />R'VIEES _ `_.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI~E3 :~ ~~ r ~~ t . e-. , t ..+`_ ~~~ o,~ 7~6
<br />r ^u
<br />CERTIFICATE OF DEATH ~ `~" ..'.:. '~ "`~'~
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX < ' ~ ~, dl`E OFflE'ATH j161o., Day, Yr.)
<br /> Thomas Ro er Knick Male `Au ust (3; X009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Slrthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Froid, Montana 78 August 23, 1930
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 269-30-3350 ~~ ^ Inpatient OTHER ^ Nursing Home/LTC ^ Moaplce Facility
<br /> 86. FACILrrY•NAME (If npt InatltUtlOn, give etreat and number) ^ ER/OUtpatient ®Decedent'8 Homa
<br />tr
<br />~
<br />U
<br />816 W. 9th St.
<br />^ DoA Q other (spacKy)
<br />~ 8c. CITY OR TOWN OF DEATH (Include Zip Code) ed. GOUNTY qF DEATH
<br />o Grand Island 68801 Hall
<br /> 9a. RESIDENCESTATE 9b. COUNTY 9c. CITY OR TOWN
<br />w
<br />z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIF CODE 9g. INSIDE CITY LIMITS
<br />~, 816 W. 9th 5t. 68801 ®ves ^ Np
<br />~ 10a. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name
<br />!`
<br />m ^ Married, put separated ^ Widowed ^ Divorced ^ Unknown Hilda Mae Vlsek
<br />~ 11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> James Carl Knick Mary Catherine Creager
<br />a
<br />E 13. EVER IN U.S. ARMED FORCES? Glve dates of service If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yes, No, or Unk.) NO Hilda Mae Knick Wife
<br />~ 15. METHOD pF DI$Pp$ITIgN 78a. EMBALMER•SIGNATURE i8b. LICENSE Np. 16c. DATE (Mp., Day, Yr.)
<br />F ^ Burial ©Donation
<br />Not Embalmed
<br />Au
<br />ust 7
<br />2009
<br /> g
<br />,
<br /> ® Cremation ^ Entpmbment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LpCATIgN CITY /TOWN STATE
<br /> ^ Removal ^ Other(Spacify)
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zlp Code
<br /> All Faiths Funeral Home, 2929 S. t.ocust Street, Grand Island, Nebraska 68801
<br /> CAU E ee nstructlons an exam les
<br /> 1a. PART I. Enhr the chain of awMa-~lasaaea, InJUdaa, pr cpmpllcatlonaihat directly Cauead the death. Do NOT enter terminal awnta such as cardiac arrest, ;APPROXIMATE INTERVAL
<br /> rseplretpry arroat, or ventricular BbHllatlon wNhout showing the etiology. DO NOT ABBREVIATE. EMar only one Hasa on a Ilne. Add additlpnal Ilnea 11 neceeaary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Renal Failure 6 Months
<br /> disease or condldpn reauNlnp
<br /> In death) pUE TO, OR AS A CONSEQUENCE pF: onset to death
<br /> Sequerrtlaly II>h condNlona, If b) Hypertension :Years
<br /> any, leading to the Hasa listed
<br /> on qne a.
<br />DUE TO, OR AS A GONSEDUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE ~) Coronary Artery Disease ;Years
<br /> (dlwaee or Injury that Inltlatad
<br /> iha events resulting In death) pUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 18. PART n. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but npt resulting In the underlying cause given In PART 1. 19. WAS MEDICAL EXAMINER
<br /> Atrial Fitlrillation, Renal Artery Stenosi5 OR CORONER GONTACTED?
<br />qC
<br />^ YES ®Np
<br />~ 20. IF FEMALE: 21 a. MANNER OF DEATH 216. IF TRANSPORTATION INJURY 27 c. WAS AN AUTpP$Y PERFORMEpT
<br /> ^ Not pregnant wlthln peel year ®Natural ~ Homicide ^ DdverlOppretpr
<br /> ^ ~.ES ® NO
<br />~ ^ Pregnant at time of death ^ Accident ^ PenAlnp Inwatipatlon ^ Paseenpar
<br />
<br />~ ^ Not pregnant, but pregnant wlthln 42 days aT death
<br />^ Suicide ^ Could not be determined ^ Pedennan 27d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />© Npt pregnant, but prepnent 43 Jaya to 1 year before death
<br />^ pthar ISpacITyJ TO COMPLETE CAUSE OF DEATH?
<br /> Unknown If pregnant wlthln the past year ^ YE$ ^ NO
<br />
<br />a
<br />E 22a. PATE DF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE pFINJURY-At home, farm, etreat, factory, office building, construction site, etc. (Specify)
<br />0
<br />u
<br />a 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~
<br />^ YES ^ NO
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITYlTOWN STATE ZIP GODE
<br />- - - - 23a, DATE IDF.BEATN (Yoc, Day, Yr.l - - - - -- . PATG~SIGNED fYr Yr.) - - 24b-TIME OF DEATH
<br /> a ~ August 6, 2009 ~
<br /> ~ r 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME qF DEATH ~ ~ ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> W J Au ust 10, 2009 11:30 AM r
<br />~ 4 a Z~Z
<br /> a O 9d. To the beat of my knowledge, death occurred al the time, date and place
<br />
<br />d d
<br />h
<br />Ti $ ~ ~ O
<br />W
<br />B
<br />34a. On the basis pT examinatlpn andlpr Inveatipatlpn, In my Oplnlon death occurred at
<br /> ue to t
<br />e cauaele) stated. ISlpnature and
<br />tle)
<br />a ~ an o U
<br />~ the lima, data and place and due to tlw teasels) stated. (Signature and Title)
<br /> ~ Kimberly A. Mickels, MD ~ ;
<br /> 25. DID TpBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DpNATIgN BEEN CONSIDERED? 2Bb. WAS CONSENT GRANTED?
<br /> ® YES ^ NO ^ PROBABLY ^ UNKNOWN ^ YES ®NO Not Applicable K 28a Is NO ^ YES ^ NO
<br /> 2 AM N A ype or r nt
<br /> Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 2Bb. DATE FILED 8Y REGISTRAR (Mo., Pay, Yr.)
<br /> August 10, 2009
<br />20090~30~
<br />ST
<br />~~
<br />
|