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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH <INQ F11.EMi4111 SEI2VIGE5, TT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA6KA DEJ�ARTNIEN� O� NEALTN AND
<br />HUMAN SERVICES, VI7"AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO�2 VI��IL RECORDS. �
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<br />DATE OFISSUANCE ��f��A� . U . � r ,�`� ``
<br />07/21/2011 2 0 �. � 01 � � � S TAItf�"EY�,S..C � Q � P t� • .. ` .,., tl, - _
<br />ASSiS7'�IN7'5Ti4'f'��E�TS7IRA,R �#
<br />� ��P�IR'T(�7� OF HEAlYP7.4Na, $ �
<br />LINCOLN, NEBRASKA H�N�9116'SER� CES ° =: {., ';,,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI �1 � �
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<br />AL�19T�C�A �TC AI!' !�C ATLI ? � • �� � � � ���y�. � � '� � � 02415
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<br />1. DECEDENTS•NAME (First, Mlddle, last, Sufflx) 2. SE3( v•, /�, S: DATE OF DEATH,�Nto., Yr.)
<br />Marlln C Suck Male ��' ��, ; C u1�6��09'9 �`=
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday b. UNDER 1 YEAR Sc. UN ER `F' p�4Y �'• B. Ell G OF BIR (Mo., Day, Yr.)
<br />(�'►a•) � MOS. DAY9 HOUR9 � �NS s � `� �� ; �� �`� �
<br />Council Bluffs, lowa 85 �;December 28, 1925
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />508 I� OSP AI. � Inpadent OTHER ❑ Nursl� Home/LTC � Hoaplee Facllity
<br />8b. FACILITY-NAME (N not I�tltutlon, give atreet ami number) � ER/OutpaNerrt ❑ DecedeM's Home
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<br />� Mary Lanning Memorial Hospital �: ooa ❑ ort�er �sPea�ty�-
<br />� 8c. CITY OR TOWN OF DEATH (includa Zip Code) 8d. COUNTY OF DEATH
<br />c Hastings 68901 Adams
<br />a ea. RESIDENCE�STATE eb. COUNTY 8c. CITY OR TOWN
<br />a Nebraska Adams Kenesaw
<br />LL 9d. STREET AND NUMBER 9e. APT. N0. 8f. ZIP CODE 8g. INSIDE CITY LINOTS
<br />�, 510 N. 4th Ave 68956 � Y�s ❑ No
<br />'° 10a. MARRAL STATU9 AT TIME OF DEATH ❑ Marrled ❑ Never Marrlad 10b. NAME OF SPOUSE (Flret, Mlddle, Last, SuRlx) H wHe, give malden �me
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<br />� ❑ 11�rrled, but separated � wnaowea ❑ onroreea ❑ unicnown ye��a HuUfnger
<br />� 11. FATHER'3•NAME (Firet, Mlddle, Last, Suffbc) 12. MOTHER'S•NAME (FUet, Mlddle, Maiden Sumame)
<br />m Carl Suck Edna Steuben
<br />Q ' 13. EVER IN U.S. ARMED FORCEST Give datea of servlCe IiY�. 148. INFORMANT•NAME 14b. RELATIONSMP TO DECEDENT
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<br />$ �r�, No, or unk.� Yes 03/28/1945-07l21/1946 JeROn Suck grandson
<br />,$ 15. METHOD OF DISPOSITION 18a. EMBALMERtiSIGNATURE 18b. UCENSE NO. 16c. DATE (MO, Day, Yr.)
<br />f ? � Burial ❑ Do�mUon
<br />Henry Opbroek 1147 July 11, 2019
<br />❑ CremaUon Q EntombmeM ��. CEME7ERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specity)
<br />Kenesaw Cemetery Kenesaw Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />Jackson-Wilson Funeral Home, 209 N. Smith Ave, PO Box G, Kenesaw, Nebraska 68956
<br />CA 5E OF DEATH See instructions and exam les
<br />1B. PART I. E�rter Ne ehaln of eve�rts-diaeaees, InJuries, or compOCationa-that dtreetly caueed the death. DO NOT aMar tertninel everrte such ae esrdiae errest, ; APPROXIMATE INTERVAL
<br />respiratory art0at, or veMriwiar flbrl�Ilaation wkhout showln8 �e eGology. DO NOT ABBREVIAT& Eirter oniy orre cau� on a Ilrre. Atld etldWonal l�nea ii necessary.
<br />IMMEDWTE CAUSE: ; onset to deatN
<br />�emeowre cnuse �� a) Acute Hypoxic Respiratory Failure E 12 Hours
<br />dl�eae or condWOn resuttlng
<br />In deam) DUE TO, OR AS A CONSEQUENCE OF: : ortset to death
<br />sey„e„n�y a8e �am,,,,, n b} Rulmonary Fibrosts : 30 Days
<br />a�y. i�m�e so ure ��� i�a
<br />on Iine a. DUE TO, OR AS A CONSEQUENCE OF: � orreet to death
<br />Enrerme ueuaannc cause �1 Pneumonia : 30 Days
<br />(disaase m inJury U�at Iniqated
<br />ure e"B"�s'es�'re"e u� de�� DUE TO, OR AS A CONSEQUENCE OF: � orreet to death
<br />usT d)
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS-Condittor� contrlbutlng W the death but �ot resulUng In the undarlying puse gWen in PART I. 78. WAS MEDICAL EXAMINER
<br />Chronic Dlastolic Congestive Heart Failure OR CORONER CONTACTED7
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 27c. WAS AN AUTOPSY PERFORMED7
<br />LL
<br />� .� Not pregnaM within paet yaer � Natural � HomiUde � DriverfOperator �� � NO
<br />U � Pregna�rt at tlme ot death � pccide�rt � Pendln8 Inveatl8�on ❑ P8 �� 8 �
<br />� � Not pree�en►. 6ut pree��tn 42 days otdeatl� � Pedestr�an 21d. WERE AUTOPSY FlNDINGS AVAILAB
<br />� Not pregnain, but pregnairt 49 days to 1 year before death � SWWde � Coula nM be determined ❑ � r �S��n) TO COMPLETE CAUSE OF DEATH?
<br />� ❑ Unimown If P�B�a�rt within the paet year ❑ YE9 ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY-At home, farm, street, factory, oftice bullding, conatruedon site, ete. (Specify)
<br />E
<br />$
<br />,S 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />F' ❑ YES ❑ NO
<br />22f. �OCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYROWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF OEATH
<br />.� July 6, 2011 � �
<br />�� r 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ���� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E Z Jul 19, 2011 05:55 PM E d< z
<br />$� o s�. ro me e�s ot my �owteaee. a� ouurr�a at sne ame, aaee �a a�� g�� o.
<br />�� � 24e. On the basls of e�mineqon anNor Investlgatlon, In my oplNon death occurred at
<br />o sntl due W the cauae(s) e[ated. (SlgnaWre and Title) � o � the dme, dale and piaee and tlue W the puse(s) stated. (Signature and Tttle)
<br />~ MiChael G. Skoch, MD '' � s
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED4 28b. WAS CONSENT GRANTED4
<br />� YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicabte H 28a la NO ❑ YES ❑ NO
<br />27. E, IT E AND DR OF CERTIFIER (PH SI , H IST T, OR P I OR O El� (Type or Prirrt
<br />Michael G. Skoch, MD, 223 E 14th St. #100, Hastings, Nebraska, 68901
<br />28a. REGISTRAR'S SIONATURE �! 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />July 19, 2011
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