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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Adrian Leonard Rerucha 2. SEX ? Male 1 DATE OF DEATH (MO., Day, Yr.) July 8„26i'4, 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Staplehurst, Nebraska 5a. AGE - Last Birthday (Yrs.) 81 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) May 14, 1933 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -46 -2664 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home 0 DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 706 Joehnck Drive e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 106. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Charlotte Sypal 11. FATHER'S -NAME (First, Middle, Last, Suffix) Leonard Rerucha 12. MOTHERS-NAME (First, Middle, Maiden Surname) , Georgia Bartunek 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 06/04/1953- 05/02/1955 14a. INFORMANT -NAME Charlotte Rerucha 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) July 14, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. 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) To be completed by: CERTIFIER I 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, r APPROXIMATE INTERVAL 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) Respiratory Failure disease or condition resulting onset to death 1 Day in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Renal Failure 1 1 Week any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death Enter the UNDERLYING CAUSE c) Congestive Heart Failure, Systolic 1 1 Week (disease or injury that initiated • the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d)Coronary Artery Disease : 10 Years 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the d--" b • not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ 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 lion ❑ Suicide ❑ Could umined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c, PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE .e w F r 1' z 23a. DATE OF DEATH (Mo., Day, Yr.) July 8, 2014 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.) July 11,2014 23c. TIME OF DEATH 12:18 PM 24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD - u O 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) f Isaac J. Berg, 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(,) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? IA YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. 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 (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 1 28a REGISTRAR'S SIGNATURE I ! 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 14, 2014 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL "RECORDS. . DATE OF ISSUANCE 07/15/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA 201404697 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV)PES „ - - CERTIFICATE OF DEATH ( STANLEY S. COOPER AS$ISTA'NT STATE`REGISTRA1 DEPARTMENroFJ-IEALTH AND HUMAN $ERV4CES 14 03423