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To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix)
<br />Leo John Mostek
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<br />- 3,'DATEXIV DEATH (Mo., Day, Yr.)
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<br />JanuarI2, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrz.)
<br />58
<br />5b. UNDER 1 YEAR
<br />Sc. UNOER I DAY
<br />641ATE BIRTH (Mo., Day, Yr.)
<br />January 25, 1956
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />505-78-9377
<br />8b. FACILITY-NAME (If not Institution, give street and number)
<br />4150 W. Highway 30
<br />8a. PLACE OF DEATH .. .
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA IE oth.tepoornighway- - - - --
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />COUNTY 9b. COUN
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER r e. APT. NO.
<br />716 S. Stuhr Rd.
<br />I 9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />Ui YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Laura Starman
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />Leo Mostek
<br />12. MOTFIER'S-NAME (First, Middle, Maiden Surname)
<br />Genevieve A Thompson
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT-NAME
<br />Laura Mostek
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />El Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />January 13, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />I To be completed by: CERTIFIER
<br />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
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Blunt Force Trauma
<br />disease or condition resulting
<br />onset to death
<br />Immediate
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Sequentially list conditions, if b) Motor Vehicle Accident 1 Immediate
<br />I
<br />any, leading to the cause listed I
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Enter the UNDERLYING CAUSE c )
<br />I
<br />(disease or Injury that Initiated .
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: r onset to death
<br />LAST d) 1
<br />1
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Autopsy revealed cuts and lacerations to several vital organs.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />al YES 0 NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />El Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />ID Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES 0 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />construction site, etc. (Specify)
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />January 12, 2015
<br />22b. TIME OF INJURY
<br />06:13 AM
<br />22c. PLACE OF INJURY-At home,
<br />Highway 30, Near Driveway
<br />farm, street, factory, office building,
<br />Of 4150 W. Hwy 30
<br />22d. INJURY AT WORK?
<br />El YES • NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Decedent was driving eastbound on Highway 30 behind a semi. The semi came to a stop to turn left into gas station.
<br />Witnesses report seeing semi use blinker. Decedent did not appear to apply brakes before striking the rear of the semi.
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />4150 W. Highway 30 Grand Island Nebraska 68803
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<br />23a. DATE OF DEATH (Mo., Day, Yr.)
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />January 15, 2015
<br />24b. TIME OF DEATH
<br />06:13 AM
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />I 23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />Janua ryl2,2015
<br />24d. TIME PRONOUNCED DEAD
<br />6 12 3 d. To the best of my knowledge, death occurred at the time, date and place
<br />2 a. and due to the cause(s) slated. (Signature and Title)
<br />24e. On the basis of examination and/or investigation, In my opinion death mewed at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Jon Hendricks, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />D YES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jon Hendricks, Hall Deputy County Attorney, 231
<br />S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE A
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<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 20, 2015
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKARE,p,f1,,RTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR .ALsEcti014.
<br />DATE OF ISSUANCE
<br />STATE OF NEBRASKA
<br />STANLEY S. COORER''.
<br />01/22/2015 201501162
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<br />' AS.§ISTANf SMTE RG1§T R
<br />,; ■ DEPASMFAIT PF-04
<br />LINCOLN, NEBRASKA ? : !WM * • ""1 ''''
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANtERYICEB , " : i' 44'
<br />CERTIFICATE OF DEATH 1 -) . '4 ' .. 15 00276
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