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<br /> STATE�F 1N1E��ASKA
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<br /> STATE 4F NEBRASKA-❑EPARTMENT OF HEALTH AND HU1�fAN�SER��,�'`�.�"��.�:�.�y�.►•���-=�-�°`�a�w�-� '�4 Q�$�7
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<br /> 1,i]�GEDENT°S-NAME[First, MiddCe, L�st, Suffix} 2.SEK 3.DATE aF�EATH tMo.,13ay,Yr.}
<br /> Mary Ltau 11Aa#zke Female Deeem�er 28,2014
<br /> 4.CfTYAHa STATE DR TERRiT�RY,�R�DREIGN GQUN7RY�F BIRTFd 5a.AGE-Last Birthday b.UND�R 1 Y�AR �vc.IJNaER 1 DAY fi.DATE O�BIRTH tMo.,Day,Yr.}
<br /> ���� MQS. DAYS HdURS M1N5.
<br /> V1lester�,Nebra$ka 87 ❑ec�mber 3,19�7
<br /> 7.50ClAE.SECLlRITY NUMB�R 8a.PLACE OF❑EATH
<br /> 5p6_�2_��p�� �os�RA� �Inpaf�ent bTH�R �NursTng HomelLTC �HospiGe FaciGty
<br /> 8b.FA�I�..ZTY-NAM�[if r�at Institution,give street and num8er] Q( EW�ufpatient �DecedenYs Hame
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<br /> � CHI Health 5t.Francis ❑D�A ❑otr�er[s�c�yy
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<br /> W 8c.GTTY�R T�WN�F❑EATH�IncludeZip Code} 8d.COLiNTY QF D�4TH
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<br /> o Grand ls(and fi88D3 HaC1
<br /> J 9a.FtE51DENGE�TATE �6.C�fJNTY 9c,.CITY DR T�WN
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<br /> � Plzh�aska !-!�!� - C=an�Isiar,;
<br /> .27 9d.STREEf AND NUMB�R e.A�T.ND. 9f.ZIP C��E 9g_1N51DE Cl�lf L1MlTS
<br /> `` 4'!8 S Woodland I]r 688Q� �v�s ❑ �[o
<br /> a
<br /> � 10�MARITA�STATl15 AT TlME�F D�ATH[]Married [�Nevsr Married 1�b.NAME OF SPOLfSE(Frst, Midr�ler l.as�, 5uffix}lfwife,give maiden name
<br /> '�y
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<br /> � [�Married,bvt separated �Wdowed �pi�as�ced ❑Unknawn ��arence Matzke
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<br /> G7
<br /> � 19.�ATHER`5-NAME{I�irstr Mlddle� L.as�, Suffix} 72�MqTHER'S-NAM�{Frs'�, Middle, Maiden 5urname]
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<br /> � Vit Kumpost Mary Parkas
<br /> � 13.EVER IK U.S:ARME�FDRCES?Give dates of service if Yes. Z4a.INFDRMANT-iVAM� 14b.RELATi�HSH[P TO 1]�C��ENT
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<br /> � �l(es,�la,ar�n�.�No Canr�ie �a�CUS ❑c'�Li�h���
<br /> � 15.METH��OF�ISPQSITI�N 96a EMBALMER�[GNATiJRE 't6fa.L1CI�NSE NO. '[6c.DATE(Mo.,�ay,Yr.j
<br /> � �]au�;� ❑�anataon �evin V11ood 13�5 Janua�y 5,2a'�5
<br /> ❑Cremation❑Entombment .��d.CEMETERY,CREMATORY�R DTHER LQCATI�N �lTY!TDWN STAT�
<br /> �]Rema�a� �Other{Specify}
<br /> Plainview Cemefery �1V'es#ern Nehraska
<br /> TTa.FUNERAL H�M�[�AME AH�MAILING ADDRESS�Street,Cify vr Town,State] 17b..�".ip Cod�
<br /> Livings�on�ondermann Funera[Home,60'� N.Vllehb Raad,Gra�d island;Nebraska 688�3
<br /> CAUSE�F DEATH See instructions and exam les
<br /> 1$.PAR"F I.Errter the chain of evertt��ciis�ases,injuRes,v�cvmplications that directly+�use[i tRe death.dO ND'T errter terminal eve�tts such as eard'iac arrest, i APPRO)CIMATE INTERVAL
<br /> respiratory arrest,or�eritrirular fibri[[ation witha�shov►nng the efialagy.�O NQ.TAB6REVIATE.Eriter anly one cause an a line,Add additiana]lines if necessary. r
<br /> IMMEDIATE CRLiSE: � onset ta death
<br /> INfM�RfATE CAUSE{Fina[ ��Res�ira.tvry Fai[ure > >1 Day
<br /> �
<br /> dtsease or condirion resultir�g �
<br /> 'n���'� Dl]E Tn,OR AS A CdNSEQU�NC�OF: E anset to death
<br /> Sequentia[[y Iist co.nd�Eions,� h}A�pira�tian Pneumonia � ��fla}(
<br /> any,leacting to the cause[isrted �
<br /> an lin�a
<br /> r
<br /> DUE TO,OR A5 A GONSEQ[J�NGE�F: � onset ta death
<br /> Enbe�the UNDEFtLYlNG CA!]5� G� . E
<br /> {disease ar injc�ry that initiated
<br /> r
<br /> the evenix resulting in death} ❑��T0,pR A5 A GONS�QUEHC�DF: � onset#o death
<br /> LAS� �} �
<br /> I
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<br /> 78.PART 1�.�THFR SIGN�FICANT CQNDITiDNS-Gnndi�inri�cantr�butir�g to the d�ati�hut nat resulting ir�fhe under�ying�ause given in PART I. 19.WAS MEDICAL IXAM�N�R
<br /> ❑R C�RQNER CQHTAGTED?
<br /> � - ❑YES �NQ
<br /> W 2Q.iF FEMALE: 27a.MAMVEROF D�ATH ��tb.IF TRANS��RTAT�OK[N,�Ui� 2��.WAS Ahf ALITOPSY PERFQRMED?
<br /> �
<br /> }-. �Hot pregnant within past year �Natural �Hvmicide �driverlDperator
<br /> � ❑v�s � No
<br /> U �Pr�egnarEt at time o(death �Accident �P�nding investigation D Passenger
<br /> �Nat pregna¢�t,but pregnarft withi�42 days of death �PeciesYrian 21 d.WERE AL�T�PSY F[NOtHGS AVAII.AB
<br /> � �suieide �Cac�ld nat he d�barmined � TC]CDMPL.ETE CA[]S�DF UEATH?
<br /> �
<br /> �Not pregna�he�t preg�aRt 43 darys to-I year befare death ��ther{SpeciTy]
<br /> � �llnlsnown�f pregnant within#F�e past year �YES ��IO
<br /> � 22a.�ATE�.F�NJURY(_.Mo..Day.Yr.] 2?.l�.T€ME OF[NJL1FtY 22e.PLAC��F thIJIJRY At hvme,farn,street;fac#or;,of�i�e 3��iidina.Ganstn���ion site,e�,s.�pec�� �
<br /> 0
<br /> �
<br /> � 22d.�NJURY AT WOFtEC? 22e.�ESCRIBE H�W INJURY OCCURRED
<br /> C
<br /> � ❑YE5 �N�
<br /> 22f.L�CATfON QF INJURY-STRE�T 8�NUM6�R,APT.NQ. GITYI�OWN STAT� ZIP CODE
<br /> Z3a.oATE�F DEA'i'H tMv.,Day,Yr.] �y_ ZA�a.QAT�SIG�IE�{M�.,Day,Yr.j 24b.TIME�F DEATH
<br /> �� C�ecemher 28,�0'{4 �a�
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<br /> �� �3b.DATE 51GNED{Mo.,[3ay,Yr:} 23c.TIME DF DEATH m�° 24c.PRDNOl1NCED O�A�(Ma.,Day,Yr. 24d.TlME PRa�fa[1NCE0 DEAD
<br /> �u z Jan�ta 5,2�'[5 ��:3�AM ���2
<br /> p. ❑
<br /> ��� _7a the hesrt of m y knowled ge,death vccurred at.thra time,date and p�ce ��� �,p�t h e h a s i s a f e x a m i n�r t i a n a n d l n r i n v e s t i g a t i o n,i r r m y o p i n i o n d e a t h a e c u m e d a t
<br /> o R ared due tq the caus�(s}Stated.4Sigriature ar�d Title) o�p the time,date art�d placs and due ia fhe tause{s)sl�ried.{Signawre and Tif1e}
<br /> `�g Jennifer L.Brawn,MD �a o
<br /> 25.E]ID TQBAGCQ USE CQNTRIBUTE TQ THE D�A►TH? �Ba:HA5�RGAN OR TlSSL1E��[�ATIQN B�EN COMSIl7�RE0? 2sb.IIVAS CDNSENT GRA�ETED?
<br /> ❑YES �iV0 �PR(]BABLY � llNKH�WN �YE5 �N❑ Nat ApplicalSle if 26a is ND ❑YE5 �N�
<br /> 2T.NAME,T1TL�AND ADDR�SS U�CERTIFIER=Type ar Print
<br /> Jennifer L.Brown,IItID,729 Nort�Custe�r A�en�e,Grand Island,Neh�aska,688�3
<br /> 2$a.REGISTRA,R'S SiGNATURE �r 28h.DAT�FILEO BY REGISTRAR�Ma.,�ay,Yr.y
<br /> January 6,2D�5'
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