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<br />STATE OF NEBRASKA ,
<br />WHEN TH/S COPY CARRIES THE RA/SED SEAL OF THE NEBRASKA HEALTHAND HUMAN'SERV/CES
<br />SYSTEM, /T CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG►NAL HECORD OK �ICE W/TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S�'AT/STICS - y , - 1i /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _- •
<br />/1�..�,��.-�� _-
<br />DATE OF ISSUAIVCE
<br />�� � ,s z00�
<br />LINCOLN, NEBRASKA
<br />20120265�
<br />+' --_
<br />�
<br />STATE OFNEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES PINANf�
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'3-NAME (Flrai, Mlddle, Laet, Sulflz) Z.'SEX
<br />T.nrr , AI.�.ea JOhASOA Male
<br />4. CITY AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH 5e. AQE-Leat Birthdey 66. UNDER t YEAR 9c. UNDE
<br />Grand Island, Nebraska �v�8.� 63 MOS. DAY3 HouAs
<br />7. SOCIAL SECURITY NUMBER
<br />505-52-3275
<br />8b. FACILITV•NAME (It not Inetitullon; give alreet and number)
<br />3031 Roselawa Dr.
<br />Ba. CITY OR TOWN OF DEATH (�nciude 2Ip Code)
<br />Grand Island 68801
<br />Ba.RES10ENCE-STATE Bb.COUNiY
<br />Nebraska Hall
<br />8d.3TREETANDNUMBER
<br />3031 Roselawn Dr.
<br />t0a. MARITAL STATU9 ATTIME OF DEATH �[ Merriad ❑ Never Menled
<br />❑ Manied, but sepereted ❑ Wtdowed ❑ Dhomed ❑ Unknown
<br />E$ �
<br />��
<br />.�, �
<br />- f<
<br />�����
<br />F A�ATE OF DEATH �M3 Day�YO'O7
<br />Y118i� �
<br />I;DAY B. DATE OF BIRTH (Mo., Day, Yr.)
<br />MINS. Ju1y 31, 1943
<br />PLACEOFDEATH
<br />HOSPITAL ❑ Inpellent 0h �21 ❑ Nursing HomeILTC ❑ Hospice Fecllfty
<br />❑ ERlOulpaUent �,DecedenPeHOme
<br />❑ D04 ❑ Other(specHy)
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />Ba CITY ORTOWN
<br />Grand Ialand
<br />Be. APT. NO 9t. ZIP CODE 8g. INSIDE CITY LIMRS
<br />688�1 ❑ YES �L NO
<br />Ob. NAME OF SPOUSE (Flrat, Mlddie, Lael, SuHix) R wife, gWe meiden neme.
<br />Franoes J Kay
<br />11. FATHER'S-NAME (Firet, ' Middle, , Leat, Sutfix) 12. MOTHER'S-NAME (Flret, Mlddle, Malden 8urneme)
<br />George (NMI) Johnaon Martha (1�IlrlI) Evers
<br />13. EVER IN U.S. ARMED FORCES? dhre dates ol servlce If yes. 14e. INFORMANT NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yea,no,orunk.] yes 5-13-68/10-18- 9�=�'�s J. �'olanson �ife
<br />15. METHOD OF DISP031TION 18a. EMBALMER•31�NATURE ` i8b. LICENSE N0. � 18c. DpTE (Mo., Day, Yr. )
<br />¢�audel ❑Doneuon �� FebrtlBLy 27 � 2007
<br />❑ Crematlon ❑ Enlombment ��• CEMETE CR MATORY OR OTHER LOCATION CITY /TOWN STATE
<br />❑ aa� ❑ Other (3peclty) Westlawn Memorial Bark Cemetery, Grand Ialand, Nebraska
<br />17a FUNERAL HOME NAME AND MAILING ADDRE3S (81reet, CNybrTOwn, 8tate) 17b. Zlp Code
<br />Rleine Funeral Home, 3213 W North F'ront St., Grand Islaad, NE 68803
<br />1& PAR7 I. Enter the cheln ai eventa-diaeases, lnjuries, or wmplicatlona-lhet directly ceused the death. DO NOT enter terminel svents euch ea cerdlec arrest, � APPROXIhMTE INTERVAL
<br />I
<br />reaplratary errest, ot ventrlculer flbrpletlon wlthoul ehowing the eUology. DO NOT ABBREVIATE Enter only one ceuse on e Iine. Add addfUonal Mes M necessary. �
<br />IMMEDIATECAU3E: � anset to daeth
<br />I
<br />II�ANEDIATECAU3E(Flnat �e� natural causes related to old age ; unknown
<br />�OO���u�n^9 DUETO,ORASACONSE�UENCEOF: I onaettodeath
<br />61 d081h) I
<br />SequenGallyilatcanditlone,it ro� �
<br />�'������ DUETO,ORA9ACON&E�UENCEOF:
<br />on line a.
<br />E� tha UNDEHLYfNO CAU38
<br />(diseaseorMJurythetinftlat�l (°�
<br />������ DUETO,ORA9ACON9EQUENCEOF:
<br />lA4f
<br />(�
<br />18. PART II.OTHER SIONIFICANT CONDITIONS-Condltione conhibuting to the death but not resulti� �n ihe underlying cause given In PART I.
<br />I onsettodealh
<br />I
<br />I
<br />t
<br />� onsel to deelh
<br />I
<br />I.
<br />18. WA9 MEDICAL EXAMINER
<br />OR CORONER CONTACTED4
<br />I� YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFOHMEDI
<br />❑ YE3 �I NO
<br />❑ Not pregnent, bul pregnenl wllhin 42 days ol death ❑ guloide ❑ Could not be delertnlned 21 d WERE AUTOP3Y FlNDINOS AVAILABLE TO
<br />❑Notpregnant,butpregnent43deyaiotyear6etoredeath ,�Other(SpecBy). ppMPLETECAU5E0FDFATH7
<br />❑ Unlmownlipregnentwtihlnthepasiqear ❑ YE9 x7 N0
<br />22a. DATE OF INJURY (Mo., Deq, Yr.) 226. TIME OF INJUqY 22c. PLACE OF INJURWAt home, term, atreel, lectory, oHice building, construction site, etc. (5pecity)
<br />February 23, 2007 7:00 am home
<br />hypertension, diabetes, resp�ratory problems
<br />20.IFFEMALE: 21e.MANNEROFDEATH 21b.IFTRANSPOHTATION
<br />0 Not pregnent withln past year L� Neturel ❑ HoMolde • ❑ Driver/Opereror
<br />❑ Pregnenl et Ume of deatb ❑ Accldent0 Pe�ing InvestlgaUon � P�enger
<br />❑ Pedeslrien
<br />22d.INJURYAT WORK9 22e: DESCRIBE HOW INJURY OCCURRED
<br />❑ YES gpNO col l apsed i n ki tchen
<br />221. LOCATION OF INJURY • S7REET & NUMBER, APT. N0. CIiYlfOWN
<br />23a. DATE OF DEATH (Mo., Day, Yc)
<br />�� 23b.DATESi�NED�Mo.,Day,Yr.) 23c.TIMEO
<br />ad�
<br />� ��
<br />° 23d.To tlre beat ol my knowiedge, dealh occurred et the time
<br />�� and due to the aeuae(s) slated. (9lgnature edd TIUe )
<br />��
<br />25. DIDTOBACCO USE CONTRIBUTETOTHE DEATHI
<br />❑ YES ❑ NO ❑ PROBABLY LI UNKNOWN
<br />Jack Zitterko�
<br />28a. FiEaI3TRAR'S SIONATURE
<br />$DQE ZIPCODE
<br />24a. DATE B�ONED (Ma. Day,Yc) 24b.TIME OF DEATH
<br />,��� . . _ � . am
<br />FDEATH ��� 24c.PRONOUNCEDDEAD(Mo.,Dey,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br />m � d� February 23, 2007 7:45 a m
<br />dale and plece � u �� 4e. On the baeis of axeminetion andlor esllgadon, In my opinlan deeth oaxurted al
<br />� .� p� the Ume, an due the cauae{s) steted. (signelure and Title )♦
<br />F� a Deputy Hal l
<br />28a. HA9 OR�AN OR TI9SUE DONATION EN CONSID RED9 . WAS CONSENT �RANTED?
<br />❑ YES Ch` NO ot Apoilcable if 28e Ia NO O YES ❑ NO
<br />Hall Count Attorne , 231 S. Locust S�., Grand Island, NE
<br />286. DATE FILED BY REOISTRAR (Mo., Day,Yr.)
<br />�� MAR �. 2 2007
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