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1 To Be CompletedNerified by: FUNERAL DIRECTOR
<br />�•■.. • •• •■■• • r v• v.■rs ■ • •
<br />1. DECEDENTS -NAME (First, Middle. Last, Suffix)
<br />Barbara Ann Morosic
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />July 14, 2013
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />78
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 4, 1935
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -38 -6271
<br />8a. PLACE OF DEATH
<br />HOSPITAL: © Inpatient OTHER: ❑ Nursing HomeILTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (B not Institution, give street and number)
<br />Nebraska Medical Center - University
<br />9c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68198
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑aner(spectiy)
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9d. STREET AND NUMBER
<br />1401 West Street
<br />9e. APT. NO.
<br />91 ZIP CODE
<br />B8883
<br />9g. INSIDE CITY LIMITS
<br />® Yes ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH gl Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Donald J Morosic
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Donald Cameron
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Helen Kotas
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes. 114a. INFORMANT -NAME
<br />(Yes, No, or Unk.) No I Donald Morosic .
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSION
<br />®Band ❑DOm11on
<br />❑Cremation. ❑Enmmbmem
<br />[Perna/al ❑Oths4spacxy)
<br />16a. EMBALMER -SIGNA E
<br />7 n,
<br />16b. LICENSE NO.
<br />o a 818
<br />16c. DATE (Mo., Day, Yr.)
<br />July 18, 2013
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />St. Mary's Cemetery Wood River Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />1s.
<br />PART I. Enter the chain of events - diseases, Injuries, or compllcatlona -that directly caused
<br />inspiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final //'1/
<br />disease d 'rcondt8on resulting a) /l A2 f / )W l f
<br />in death f1 e/ WI � t
<br />�CONSEQUENer
<br />the death. DO NOT enter terminal events such as cardiac attest, APPROXIMATE INTERVAL
<br />Eater only one cause one ling. Add additional lines if necessary.
<br />onset to death
<br />1 ' /J ) Qu r._.5
<br />i {,
<br />r vt A , `� n
<br />NNAA
<br />DUE TO, OR AS :
<br />Sequentially list conditions, If
<br />any, leading to the cause listed b) �j' t "tfir,/ -A �7 Q _ _7 ,i1•��.01
<br />on lino Oi
<br />onset to death
<br />h t -e- f_j
<br />�" L
<br />onset to death
<br />a. DUE TO, OR ASIA CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that Initiated . ( a
<br />ft
<br />c \v s �
<br />the events resulting In death) DUE TO, OR A CONSEQUENCE OF: onse o death
<br />LAST
<br />_ d)
<br />18. PART II.OTHER SIGNIFICANT CONDmONS- Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES jp
<br />20.1F FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />['Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />'I)`I Natural ❑ Homicide
<br />�❑" Accident ❑ Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES �e
<br />-
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES V'FiO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />a�
<br />- 0 ii:
<br />TT; W 2 3b.
<br />0-Ic)
<br />2 LI
<br />5
<br />23a. DA OF DEATH (Mo., Day, Yr.)
<br />// �/ 3
<br />a
<br />c 0
<br />m = 0
<br />EIP Z
<br />° W z
<br />1 2 0 0
<br />t"
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />DATE SI (Mo., Day, Yr.)
<br />20, 3
<br />23c. TIME OF DEATH n
<br />//i :Z P m
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. T t of my knowledge, death occurred at the time, date and place
<br />and du to the ca . s) stated. (Signature and Title)
<br />irif /
<br />24e. On the basis of examination andlor investigation, in my opinion death occurred
<br />at the time, date and place and due to the causes) stated. (Signature and Title)
<br />26. DID TOBACCO USE C ' TRIBUTE To rDEATH?
<br />❑ VES WO ❑ PROBABLY ❑ UNKNOWN
<br />-
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES
<br />26b. WAS CONSENT GRANTED?
<br />Not Not Applicable N 26a is NO ❑ YES Xili0
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />eT . j q/i'fJ *l> A/ ,,Ai r114 /VP/11C,, l 7ler 4,ndr1e,
<br />.tic 4 -
<br />' /gf 5M'
<br />28a. R SIG R
<br />.,�..
<br />lab DATE FILED eY REGISTRAR 'Mo., ,^.. -,,, Yr.)
<br />AU6 0 6 2013
<br />201402761
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 352125
<br />PCDTICII+ATG AC F ATaJ
<br />This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas
<br />, County Health Dept, Omaha, Nebraska. Certified copies must have a raised seal in the area to the left.
<br />Reproduction of this green certificate are not legal copies.
<br />Date Issued: AUG 0 6 2013 Registrar : ..�`T�
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