Bisignano, Margaret P ART MENT OF HEALTH AND FAMILY SERVICES
/ision of Public Health Wis.Stats.,Chapter 69
'H 5045(Rev.07/04)
REPORT FOR FINAL DI8POSI1ON OF A HUMAN CORPSE �•1 lot
AND OUT-OF-STATE BURIAL TRANSIT PERMIT t�
To be Completed by a Wisconsin Licensed Funeral Director or Person Acting as Such
TYPE OR PRINT IN PERMANENT BLACK INK.
1.NAME OF DECEASED (First/Middle/Last) 2.SEX 3a.DATE PRONOUNCED DEAD(Month/Day r Yr.) 3b.TIME PRONOUNCED
Hour Min
Margaret Francis Bisignano D M ®F April 9, 2011 10:30 AM M
3c.DATE AND TIME PERSON IN 18b NOTIFIED OF DEATH 4.AGE or CI Stillborn 5.CITY,VILLAGE,TOWNSHIP OF DEATH 6.COUNTY OF DEATH
(Month/Day/Year) Hour Minute
April 9, 2011 01:00 PM M 90 Weston Marathon
7.PLACE OF DEATH (Check one if died in hospital.) 8.OTHER PLACE 9.NURSING HOME LIC.NO. 10.HOSPICE STATUS
0 Inpatient 0 DOA from NH 0 DOA from Other 0 NursingHome CBRF Residence of Decedent (Do not list CBRF or hospice hospicePatipict enrolled f
❑ ® license.) at time of death?
['Outpatient 0 ER from NH DER from Other 0 Other(Specify) ❑ Yes ® No
11a.NAME OF INSTITUTION AND CAMPUS (Or Name of Hospice Organization) 11 b.COMPLETE MAILING ADDRESS OF INSTITUTION OR HOSPICE
Decedent's Residence 7410 Gusman Road Weston, WI 54476
12a.DEATH PRONOUNCED BY(Only professionals listed may pronounce death. A hospice R.N. 12b.NAME OF PERSON WHO PRONOUNCED DEATH
may only pronounce death in certain circumstances.) (Check one.)
®Physician ❑Coroner/M.E.or Deputy ®Hospice R.N.(Item 10 must be'Yes") Ann Peterson
Death Certificate Medical Certifier Information 13.DEATH CERTIFICATE TO BE SIGNED BY
' The medical certifier must be one of the following:
Physician with a valid Wisconsin physician license(not 151 year resident) NAME Anshu Varma TITLE Dr
Physician with a temporary Wisconsin physician license
Other licensed physician working in a Veteran's Hospital ADDRESS 3501 Cranberry Blvd, Weston, WI 5447 6
Coroner/Medical Examiner or Deputy Coroner/Medical Examiner
14a. NOTIFICATION OF CORONER OR MEDICAL EXAMINER REQUIRED? (See list in item 17 and check with the 14b. COUNTY OF INCIDENT, (If 14a is"Yes")
CoronerfM.E.of jurisdiction regarding county policies. Reportable deaths must be reported prior to removal of body and embalming.)
❑Yes ®No
Information in items 15-28b is for Funeral Director,Coroner/Medical Examiner and Local Registrar use and for out-of-state transit. It is not open to public inspection.
ITEMS 15-16 MUST BE COMPLETED ON 15a.MANNER OF DEATH (As listed on death certificate) 15b.CAUSE OF DEATH(General Description from the death
CREMATORY COPY FOR DIRECT CREMATIONS ❑Natural ❑Homicide ❑Accident certificate)
AND FOR OUT-OF-STATE TRANSIT COPY ONLY 0 Undetermined 0 Suicide 0 Pending
16.COMMUNICABLE DISEASE ALERT.Is any communicable disease or condition documented in the decedent's medical record which indicates the isolation techniques(above
universal precautions)should be used for preparation and embalming? ❑ No ❑ Yes If"Yes,"provide details to authorized persons on a separate document.
17.CHECK APPLICABLE BOX(ES)IF DEATH IS REPORTABLE. (Case to be reported to the Coroner/M.E.under Wis Stats.30.67,346.71,350,155,979.01 and 979.025)
• For a case reported in 1-10,the Coroner or Medical Examiner must sign the death certificate(unless it is determined that the initially reported condition played no role in the cause of death).
• For certain cases reported under item 11,a Coroner or Medical Examiner may waive jurisdiction for signing the death certificate.
❑ 1.Homicide or suicide(includes homicide due to acts of bioterrorism) Local Registrar Certification for International Transit
❑ 2.Death following a recent accident,even if the injury is not the underlying cause of death
e.g.,hip fracture still significantly affecting the health of the decedent at the time of death)
❑ 3.Death following an old injury(no time limit) if the injury significantly affected the health of a patient
at the time of death(e.g.,death from renal failure due to quadriplegia due to old gunshot wound)
❑ 4.Death due to poisoning
❑ 5.Death following abortion
0 6.Death involving motor vehicle,snowmobile,all-terrain vehicle or boat
❑ 7.Death with no physician or accredited spiritual healer in attendance 30 days preceeding death
❑ 8.Death of a correctional inmate
❑ 9.When,after reasonable efforts,the physician cannot be obtained or will not sign the death record in time or
in an emergency situation as determined by the Coroner/Medical Examiner
❑ 10.Death with unexplained,unusual or suspicious circumstance(includes sudden unexplained death at any age)
❑11.Death reportable under individual county Coroner/M.E.policies(e.g.,24-hour rule,home deaths) SIGNATURE-Local Registrar Date Signed
FAMILY DISPOSITION. If a family member transports a body for final disposition,the family member must personally prepare for and conduct the final disposition. He or she must
complete the death certificate,obtain the medical certification of cause of death,and file the death certificate with the appropriate Register of Deeds(or the Milwaukee or West Allis
City Health Office)[Wis.Stat.69.18(1)]. For cremation,the family must obtain a release to cremate from the appropriate Coroner or Medical Examiner(Wis.Stat.979.10).
18a.STATUS OF PERSON REMOVING BODY 18b.NAME OF FUNERAL DIRECTOR (Or Person Acting as Such) 18c.WIS FUNERAL DIRECTOR
[I Wisconsin Licensed Funeral Director 0 Immediate Family LICENSE NUMBER(If applicable)
❑Coroner/Medical Examiner Office (Body storage or disposition) John J. Buettgen 5249
18d.FUNERAL HOME NAME (If applicable) 18e.MAILING ADDRESS OF FUNERAL HOME (Or Person Acting as Such)
John J. Buettgen Funeral Home 948 Grand Ave. , Schofield, WI 54476
19.SIGNATURE-Funeral Director(Or Person cting as Such) 20.PHONE NUMBER 21.DATE SIGNED (Month/Day/Year)
y ( 715 ) 359-2828 April 12, 2011
22.EXPECT F TYPE OF SPOSITION 23.E ECTED DATE OF DISPOSITION 24.EXPECTED PLACE OF DISPOSITION(Name of Cemetery or Crematory)
❑Burial ®Cre ation ❑Entomb. Month/Day/Year)
❑Donation to Medical School 0 Unk. Pending Apr 20, 2011 0 Pending Pine View Crematorium
25.CITY,VILLAGE OR TOWNSHIP OF DISPOSITION 26.COUNTY 27.STATE 28a,ORIGINAL TO 0 Register of Deeds(Or Milwaukee or West Allis CHO)
Queensbury NY
28b.COPY TO 0 Coroner/Medical Examiner 0 Cemetery/Crematory
f Out-of-State Transit
IMPORTANT NOTES J
• This form must be sent to the local registrar(register of Deeds or Milwaukee or West Allis City Health Office)within 24 hours of death(Wis.Stat.69.18).
• This form must be sent to the appropriate Coroner/Medical Examiner(usually the Coroner/Medical Examiner in the county of death)within 24 hours of death(Wis.Stat.69.18).
■ If item 17 indicates the case was reportable under Wis.Statutes,this document must be filed with the Coroner/Medical Examiner listed in item 14b.
• The filing of this document does not constitute notification of the Coroner/Medical Examiner under Wis.Stat.979.01.
• This document is not required for in-state disposition of a stillbirth. For out-of-state transit of a stillbirth,this document must accompany the body hospital,but is not filed with the local
s of a fetus 20 weeks or
tional age or 350
registraretiTi ion of he a,eanftde- oxamneonata/diner. For eatbhshthe funeral homemusr venorm�est a!status of the neonate(liveborn or srams or more t Ibom)before removing the body to inl file a fetal death Sufe 1eg81
1 documentation of the event, fY lJ
I( ■ Failure to comply with filing requirements for this document could result in a fine of not more than$1,000 or imprisonment for 90 days or both phis,stets.69.24(2)(d)],