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1. DECEDENT - NAME FIRST MIDDLE LAST <br />Edward Donald Sekora <br />2. SEX - <br />Male. <br />3. DATE OF DEATH (Month. Day. Year) <br />May 13, 2003 <br />4. CITY AND STATE OF BIRTH Of not in U.S.A.. name country) <br />Clay County,. Nebraska <br />5a. AGE - Last Birthday <br />(Yrs 82 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day. Year / <br />(� <br />November 15, 1920 <br />51). . MOS. i DAYS <br />5E. HOUR MINS. <br />S <br />7. SOCIAL SECURTIY NUMBER <br />505 -20 -7373 <br />8a. PLACE OF DEATH <br />HOSPITAL: ❑ Inpatient OTHER: X Nursing Home <br />8b. FACILITY - Name (0 ,iot institu0on, give street and nrimber) <br />V INC, Grand Island <br />❑ ER Outpatient ❑ Residence <br />❑ DOA ❑ Other /Specify) <br />2813. TIME OF DEATH <br />M <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />Grand Island <br />8d. INSIDE CITY LIMITS <br />Yes [ No ❑ <br />85. COUNTY OF DEATH <br />Hall <br />ga. RESIDENCE STATE <br />Nebraska <br />913. COUNTY <br />Hall <br />9c. CITY, TOWN OR LOCATION <br />Grand Island <br />9d. STREET AND NUMBER (Including Zip Code) <br />1527 Windsor Road 68801 <br />9e. INSIDE CITY LIMITS <br />Yes No <br />10. RACE - (e.g., White. Black. American Indian, <br />etc./ (Specify) <br />White <br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc) <br />( Specify) <br />Czechoslovakian <br />12. MARRIED ❑ WIDOWED <br />EVER <br />1: N MARRIED DIVORCED <br />13. NAME OF SPOUSE III wife. give maiden name) <br />Lipovsky': L <br />Maria - �c+ .ker- - <br />148. USUAL OCCUPATION (Give kind of work done Owing most <br />of working roe, even if retired) - <br />Farmer <br />14b. KIND OF BUSINESS INDUSTRY <br />Agriculture <br />15. EDUCATION (Specify only highest grade completed) <br />Elementary L <br />/ S condary 10 -12) - College 11 -4 or 5•I. <br />I <br />16, FATHER - NAME FIRST MIDDLE LAST <br />William Henry Sekora <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Lula A Pet! <br />18. WAS DECEASED <br />(Yes. no. or unk.) <br />1 Yes <br />EVER IN U.S. ARMED FORCES? <br />pf yes. give war and daces of services) <br />I WWII 8,/42 - 10 / 45 <br />19a. INFORMANT - NAME <br />Marie Sekora <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART <br />II Depression <br />PART 81 0 FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />(Ages 10-54) Yes n No n <br />24 AUTOPSY <br />Yes N No n <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />Yes n No nX <br />26a <br />• Accident II Undetermined <br />II Suicide I Pending <br />II Homicide Investigation <br />26b. DATE OF INJURY (Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />M <br />26d. DESCRIBE HOW IN,JRV OCCURRED <br />26e. INJURY AT WORK 261. Whce building e (bpeA-t homf, farm. street. factory <br />Yes ❑ No II ci0' <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />I y <br />g <br />8t <br />0 m <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />May 13, 2003 <br />� �l <br />E a <br />1 t <br />28a. DATE SIGNED (Mo.. Day. Yr.) <br />2813. TIME OF DEATH <br />M <br />2713. DATE SIGNED (Mo.. Day. Yr) <br />5 -15 -2003 <br />27c. TIME OF DEATH <br />1605 P <br />M <br />28e. PRONOUNCED DEAD (Mo.. Day, Yr.) <br />28d. PRONOUNCED DEAD (Howl <br />M <br />27d. To the best of my knowledge. death occurred at the ti . e, date 88d place and due to the <br />` causeis) stated. (y �I y r 1 ----- <br />(Signature and Tide) / ,, O1 � <br />.8 ,. <br />0 ° ¢ 26e. On the basis of examination and�or investigation, in my opinion death occurred at <br />~ <br />° a the time. date and place and due to the cause(s) stated. <br />r (Signature and Title) IA <br />29. DID TOBACCO USE CONTRIB�I TE TO DEATH? <br />❑ YES 55 NO ❑ UNKNOWN <br />30.8 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />ill YES ❑ NO <br />30.b WAS CONSENT GRANTED? <br />❑ YES El NO <br />31. NAME AND ADDRESS OF CERTIFIER !PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) <br />Neena Biswas MD, Neb ska /Western owa HCS, 2201 N Broadwell, Grand Island, Ne 68801 <br />32a. REGISTRAR <br />i <br />32b. DATE FILED BY REGISTRAR (Mo.. Day, Yr) <br />MAY 21 2003 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM‘ IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />ES. COOPER <br />5/22/2003 201406086 ASSIST-ANT STATE YREGSTRAR <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM- <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH . - 03 05691 <br />20. EMBALMER - SIGNATURE 8 LICENSE NO. <br />.943 <br />FUNERAL HOME - NAME G <br />Curran Funeral Chapel <br />219. METHOD OF DISPOSITION <br />Dit Burial ❑ Removal <br />❑ Cremation ❑ Donation <br />21b. DATE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />3005 South Locust St. Grand Island, NE 68801 <br />5 -17 -03 <br />3168 W. Stolley <br />yC <br />1913. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO, CITY OR TOWN. STATE. ZIP) <br />1527 Windsor Rd. Grand Island, NE 68801 <br />23. A IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). Ib). AND (c)) <br />PART Cardio - Respiratory Failure <br />lal <br />DUE TO, OR AS A CONSEQUENCE OF' <br />(b) Brain Cancer <br />DUE TO, OR AS A CONSEQUENCE OF: <br />)c) Brain Edema <br />21c. CEMETERY OR CREMATORY NAME <br />Grand Island Cit <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN <br />emeter <br />STATE <br />Park Rd. G.I., NE 68801 <br />Interval between onset and death <br />Few Minutes <br />Interval between onset and death <br />Several Months <br />Interval between onset and death <br />Few Weeks <br />