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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Clemence Edward Ziola 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) January 18, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ashton, Nebraska 5a. AGE • Last Birthday (Yrs.) 78 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) November 15, 1932 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -34 -6807 8a. PLACE OF DEATH - HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip, Code) Grand Island 68803 8d. COUNTY OF DEATH I ° Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9e. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 711 West 10th St. APT. NO. St. ZIP CODE I. 68801 9g. INSIDE CITY LIMITS M YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced 0 Unknown lab. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name June H Modesitt 11. FATHER'S -NAME (First, Middle, Last, Suffix) Edward Ziola 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Katherine Slobaszewski 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME June H Ziola 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Tracey Dietz lob. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) January 23, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska h7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1 To be completed by: CERTIFIER 18. PART I. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Six Days respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Sepsis,incarcerated Hernia With Perforation disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18_ PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. Coronary Disease,peri feral Vascular Disease,diabetes,hypertension 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO F FEMALE: Not pregnant within past year El Pregnant at time of death Not pregnant, but pregnant within 42 days of death ID Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Ion ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE.CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) January 18, 2011 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 18, 2011 I 23c. TIME OF DEATH 11:40 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 9d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jane A. McDonald, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, YSICTAN ASSISTANT, CORONER'S PHYSICIAN ORCOUNTY ATTORNEY) (Type or Print) Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 I 28a. REGISTRAR'S SIGNATURE /} ' A /�"__ - � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 26, 2011 I DATE OF ISSUANCE 01/28/2011 LINCOLN, NEBRASKA 201400607 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF? HEALTH,,,4411 71 1Z1)IYtl 6 RVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA pEPAR :ME NT Qf" EALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY bR,VITAL REC,ORQS . • Z STANLEY S. cQQPE „„,.,, T.AN' STAt4 E I,S7RAl ' r a DEPARTMENT OF HEALTH AND , .' HLJ'1AN SERVICES .,�. v 11' 00238