|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTN~A'ND HC`IMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA Q~'P,~Y1W~l~l,T~(~F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIjjA'Lw'R~C"p1dD5, • ~, a. ; J .
<br />F
<br />DATE OF ISSUANCE ' •~~_ ;
<br />04/16/2010 C STANl:EY ~ . COQP~~ ~ r "'•
<br />~01003~5~
<br />A$S.~S7k1 NT~,STATE REGIS ~RAR
<br />DEP,~TMENT d F HEAL H AND '
<br />LINCOLN, NEBRASKA H(1MAN,SEkVIC~S" •~ -
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC~$~ •, , ~, ~ ~ `: ~ ~; ~ •
<br />CERTIFICATE OF DEATH ,'• ". ~ E`t ~~ ~;'.'t,''"~ ,~ 10 01038
<br /> 1. pE"CEDENT'S-NAME (First. Middle, Lasq SuHlx) 2. SEX $
<br />DATE` F DEATH (Mo., Day, Yr,)
<br /> Duane Elbert Hoag Male ° ~ • ~
<br />J/
<br />1 bpril 10, X010
<br /> 4. CITY AND STATE OR TERRITpRY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATEpF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Lebanon, Kansas 89 November 3, 1920
<br /> 7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br /> 506-09-5598 HOSPITAL ^ Inpatlant OTHER ®Nureing Home/LTC ^ Hospice Facility
<br /> 8b. FACILITY-NAME (If net Instltutbn, ghre street and number) ^ ER/putpatlent ^ Decedent's Nome
<br />lY
<br />~
<br />U Grand Island Veterans Home ^ DOA ^ Other(Speclfy)
<br />~ Bc. CITY OR TOWN OF DEATH (Include Ztp Code) 8d. COUNTY pF DEATH
<br />o Grand Island 68803 Hall
<br /> 9a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER e. APT. Np. 9f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />~, 511 E. Memorial Drive 68801 ®Yes ^ No
<br />.~ 1oa. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, SuHlx) M wife, glue maiden name
<br /> ^ Married, but separated ^ Wldowad ^ Divorced ^ Unknown Ella Meyer
<br /> 11. FATHER'S-NAME (First, MIdd1®, Last, 8uTflx) 72. MOTHER'S•NAME (First, Middle, Maiden Surname)
<br /> Miles Hoag Delilah Watson
<br />~' 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT•NAME 14b. RELATIpNSHIP TO DECEDENT
<br />$ (Yes, No, or unk.) Yes 01!26/1943-03/12/1946 Ella Hpa Wife
<br />a 15. METHOD pF DISPOSITION 18a. EMBALMER-SIGNATURE 18b. LICENSE NO. 18c. DATE (MO., Day, Yr.)
<br />F~„ ®Burlal ^ Donation
<br />Derek Apfel
<br />1240
<br />April 14, 2010
<br /> ^ Cremation ^ Entombment
<br /> Led. CEMETERY, CREMATORY OR OTHER LOGATIpN CITY /TOWN STATE
<br /> ^ Removal ^ ether (Specify)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL NOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zlp Code
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> AU DEA ee nstrucUons and exam les
<br /> 1e. PART 1. Enrol the chain of aveMa• NIIKawa, InJurka, or cgmpllca[Igna-that directly caused the death. DO NOT enter tertnlnal ewMo such as prdWc arroat, APPROXIMATE INTERVAL
<br /> reaplratory prroal, Or Ventricular flbAllatlon wtthout ahowing the etiology. DO NOT ABBREVIATE. Enter Onty one cause qn a Ilne. Add addltlgnal Ilnea If necessary.
<br /> IMMEDIATE CAUSE: ~ onset to death
<br /> IMMEDIATE CAUSE IFIneI Bl Congestive Heart Failure 1 Week
<br /> die6ae6 or Condttlgn reaulting
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: p onset to death
<br /> Sequentlalty net condltldna, 11 b)
<br /> any, leading to the cauw Iinad
<br /> on nrw a.
<br />DUE TO, pR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (dlpaas qr InJury that Inklated
<br /> the events rosutting In daatnl DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> usT d)
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS•Condltlone contributing to the death but not resulting in the underlying cause given In PART 1. 79. wA3 MEDICAL. EXAMINER
<br /> Weight Loss; DySphagia, History Of CerebrOVaSCUIarAccidtnt OR CORONER CONTACTED?
<br />~ ^ YE$ ®NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFpRMEp7
<br />~ ^ Not pregnant within peat year ®Naturel ^ Homicide ~ Dnwr/dperator
<br />
<br />U
<br />^ Pregnant at time of depth
<br />^ Accident ~ Pvntllnp Invsstlgatlon
<br />©Paasenger ^ YE$ ®NO
<br />
<br />~` ^ Nat pregnant, but prognarrt wkhlq 42 days of d6attt
<br />^ suicide ^ Could net be deNrmined ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />^ Not pregnant, but pregnard 43 days to 1 year beloro death
<br />^ Other (apsclfy) TO COMPLETE CAUSE OF DEATH?
<br /> ^ unknown If pregnant within the past year ^YES ^ NO
<br />~
<br />~ 22a. DATE pF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, offlca building, eonstruetion site, etc. (Specly)
<br />s
<br />~' 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~
<br />©YE5 ^ NO
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITY/7pWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATESIGI~eQ~Mo., Day, Yr.) - 24b. TIME OF DEATH
<br />.. .. - - - - - - _._ _
<br /> ~ ~
<br />~,.~ AprlF10, 2~tfi0
<br /> r 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME DF DEATH ~
<br />24c. PRONOUNCED pEAp (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> s
<br />E ~ ~ Aril 12, 2010 10:27 AM
<br />~ z
<br /> ~ y r
<br />~ 3tl. To the beat of my knowledge, death occurred al the time, data antl place ~ $ O
<br />w 7 446. On the beats of examinatlon and/qr Imeatlgadgn, In my opinion death occurred at
<br /> c and due to the rauaa(aJ orated. (Signature and TnIaJ
<br />$ ~ O the Lima, data and place and due to th6 cauw(aJ stated. (Signature and Title)
<br /> w
<br />~ Jennifer King, MD ~ ~
<br />8°
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS pRGAN OR TISSUE DONATION BEEN CONSIDERED9 28b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^YE5 ®NO NotAppllcable M28a Is NO ^YES ^ NO
<br /> ,I A ,
<br />ype or rant
<br /> Jennifer King, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> April 15, 2010
<br />
|