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_� STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OE THE NEBRASKA DEPARTMENT OF HEAL7H AND-
<br />THE BELOW TO BE A TRUE COPY OFTHE ORIGINAL RECORD ON FILE WITH THE NEBRASKA D�P�
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VItAt'R�
<br />DATE OF ISSUANCE ��� �''-
<br />STAi1tLC� �:: C.�J�EI
<br />01/11/2012 �,v 120 2 2 3 2 A }
<br />DEPA v �'�?f�lE
<br />LINCOLN, NEBRASKA HUME�RN��2�'� �
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE� ''� � ,, ==
<br />SERVIC,�S, IT CERTIFI€S
<br />� OF FfEA�TH AAFD
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<br />CERTIFICATE OF DEATH � �".� . "� �'� �, �, � � �.�;T � _�,�' ;""' .
<br />1. DECEDENTS-NAME (Flrst, Middle, Last, Suftt:) 2. SFX :,' ;��, DATEO�. �AZ}I_(M, .� DaY Yr:r,
<br />Shlrley Jean Zlemba Female c�,' J�nirary 9,.2012 .�
<br />4.'CITY AND STATE OR TERRITORY, OR FOREIGN CpUNTRY OF BIRTH 5a. AGE • Lest Birthday b. UNOER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />��•) M0.4. DAYS HOURS MINS.
<br />Palmer, Nebraska 64 January 27,1947 '
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />50&54-3509 os H PRAL ❑ trmaUeM OTHER � Nursing Homa/LTC � Hospice Facflily
<br />8. FACILITY•NAME (N not I�Utution, give street a�u! �wwmber) � ER/0utpaUent � Decedent"e Home
<br />� _
<br />� 910 S. Gunbarrel Road ❑ DOA ❑ otner (spec�y�
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<br />� 8C. CITY OR TOWN OF DEATH pnclude Zip Code) 8d. COUNfY OF DEATH
<br />c Grand Island 68801 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNTY 8e, CITY OR TOWN
<br />Z ' Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER . APT. NO. 8L LP CODE 9g. INSIDE CITY LIMRS
<br />�, 910 S. Gunbarrel Road 68801 ❑ v�s � No
<br />� 1Qa. MARITAL STATUS AT TIME OF DEATH � Martled � Never Married 10b. NAME OF SPOUSE (Flrst, Amddle, Last, Suffix) Nwffe, ghe malden name
<br />� nn��ea, n�e ee�►acea ❑ innao�a ❑ on�or�d p u�oWn
<br />z ❑ Ronald Ziemba
<br />� 11. FATHER'9-NAME (First, Middle, Last, Suff6c] 72. MOTHER'3-NAME (First, Middie, dlalden Siarmme)
<br />m James Davis Evelyn Scott
<br />°' 13. EVER IN U.3. ARMED FORCES? Oive datea of servlce if Y�. 14a. WFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
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<br />$ �re8, n►o, or unk.� No Ronald Ziemba Husband
<br />,� 1$. d1ETHpD OF DISPOSI170N 18a. EMBALdIERSIGNATURE 76b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ,[] Burial ❑ Dormtlon
<br />Not Embalmed January 9, 2012
<br />� CremaUOn � ErKombmerh �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY!'FQYVN STATE
<br />' p Removai ❑ aner (spec�ry) Central Nebraska Crematlon SeMces Gibbon Nebraska
<br />17a. FUNERAL HOME NAME'AND MAILING ADDRESS (Streey City or Town, Sfate) 776. Zip Code
<br />Apfel Funerai Home,1123 W. 2nd, Grand island, Nebraska 68801
<br />CAU E F D TH See instructions an exam les
<br />18. PART L E�rtertlre thaM ot eve�ne-�d�, lnjurles. w compliratton�tiut dtrecdY wused tlre death. DO NOT eMer termbml erente m�cb as cardlac ar�st, � APPROXIMATE INTERVAL
<br />wspirarory artest, or veMriwlar flbrlllaSlon without ahowing the edology. DO NOT ABBREYIATE. Frrter only o�re eauae on e Wre. Add addBlo�ml Ihree H meessery.
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<br />ImMEDU1TE CAUSE: ; or�set to death
<br />m�oar� causE � a) Respiratory Failure i< 24 Hours
<br />ereease or cmmffton r�unine
<br />i ��� DUE TO, OR AS A CqNSEQUENCB OF: � o�et to death
<br />s�,,,a,nmu, u�s �o�, a b) Metastatic Colon Cancer ; 2 Years
<br />a�n. ��ame m u,e c�e nama •
<br />on Me a DUE TO, OR AS A CONSEQUENCE QF: f ormet to death
<br />E�Rer ttre UNDERLYINQ CAUSE G� . .. �
<br />. (dl� or mJury thae IMtlatetl� � - . . . � . -
<br />� ree"�U"g m deat�'� DUE TQ, OR AS A CbNSEQUENCE OF: ; o�et to death
<br />a� ;
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<br />18. PART II.OTHER SIGNIFlCAN7' CONDI770NS�CorMftions contributing to the death but oot r�ulUng In the urMariy(ng cause giyen In PART I. 19. WAS MEDICAL EXANANER
<br />' OR CORONER CONTACTED?
<br />� � Q YES � NO
<br />� 20. IF FEMALE: 21a MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21a WAS AN AUTOPSY PERFORMED?
<br />� � Na a�� � r�r � r�wr� 0 Ho�aaa ❑ uri�enoa�r � trES � No
<br />v p v�a �t w� m a�rn ❑ a�aa�a p v� u�ue� ❑ a�"ea•
<br />� �] Not P�aB�e�rt. but P�M wRhin 42 daYe o1 death ❑ � � PedeBMan 21d TO COIV�LETE CAUSE OF DEAAILABLE
<br />swaa. cowa �roe ue ae�ermurea
<br />� Not p►agnant, but WBB�t 44 daye l01 year before death - � Ofltet (si�fY) �� YES ❑ No
<br />� � Unimewn H pregnant Wihln the pest year
<br />E 2?a. DA7E OF INJURY (Mo., Day, Yr.) Y1b. 77ME OF MJURY 22a PLACE OF INJURY•At home, farm, etreet, Tactory, oftice 6uildUig, wnstruetion site, eta (Speeity)
<br />$
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />1�-
<br />❑ YES ❑ NO
<br />22{. LOCATION OF INJURY • 9TREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE S�ONED (Mo, Day, Yra 24b. TIME OF DEATH
<br />S I � January 9, 2012 .� �
<br />� 23b. DATE SIONED (Mo., Day, Yr.) R3c. TIME OF DEA'rH �� y 24c. PRONOUNCED DEAD {Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />�; � Janua 9, 2012 05:05AM � a�
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<br />$.... �. . To the Oeat oT mY knowledga. deatl� occurted at the Ume. date antl ptace � 24e. Oa the ba�s Me�mmt�mdun maUor Invasfl9��. � oPlnion Aeatb oxurted et
<br />o � ana aw eo ure mase(e) emmd. �s�¢nanue ana nuel e $ are dme. aam ami Wace ami due wure museleJ smeed. lsienanue ana nue)
<br />'" � Jennifer L. Brown, MD '' � �
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATHT 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIOEREp? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑' PROBABLY ❑ UNINIOWN ❑ YES � NO Not Applieable H 28a is NO ❑ YES ❑ NO
<br />27. CERTIFIER (PH G T, R ER U A ype or PrIrR
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />2Sa. REGISTRAR'S SIGNATURE � 28b. DATE FlLED BY REGISTRAR (AAo, Day, Yr.)
<br />January 10, 2012
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