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Rpv 194 <br />O <br />O <br />T <br />C <br />7 <br />0 <br />U <br />O <br />N <br />E <br />(0 <br />X <br />U <br />Z E <br />W <br />C) N <br />W <br />U U <br />W <br />L <br />LL. a <br />o�0 <br />LJJ a) <br />Q <br />Z LL- <br />c') <br />M <br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH �� ry <br />BUREAU OF VITAL STATISTICS/ `� <br />CERTIFICATE OF DEATH <br />!J �( MtUr I,a1V �t <br />PART <br />I <br />TO. OR AS A <br />Ib) <br />DUE TO. <br />I � I <br />I <br />I 1baNeen onset <br />I <br />i <br />I Interval between onset and death <br />I <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not relalod PART <br />PART PREGNANCY <br />1 DECEDENT NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH (Month DIY YNd <br />Hope NMN Rott <br />Female <br />Aril 21, 1997 <br />a rD v AND STATE OF BIRTH In nd h US.A.. name counrryl <br />Sa AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6, DATE OF BIRTH /Mooft Day. Year) <br />6b MOST DAYS <br />5c. HOURS MINS <br />IVrs.l <br />28e. INJURY AT WORK <br />Chico o, Illinois <br />79 <br />Homicide lnvestigation <br />Vey ❑ No ❑ <br />December 18 1917 <br />SI ,"IAL SECURTIY NUMBER <br />Pa PLACE OF DEATH <br />HOSPITAL. ❑ Inpatient OTHER: ® Nursing Home <br />505 -52 -4753 _- <br />❑ EA Outpatient ❑ Residence <br />Ph FACILITY Name fd nor msatunon, give street end number) <br />Tiffany Square Care _ <br />❑ DOA ❑ Other,Speafy) <br />Fr. CUV TOWN OR LOCATION OF DEATH <br />6A INSIDE CITY LIMITS <br />Be COUNTY OF DEATH <br />Grand Island <br />Yes [I No El <br />I Hall <br />27b DATE SIGNED /Motl DRRay. Y!1 <br />9P RF. IDENCE - STATE <br />9b. COUNTY <br />9c CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /mckrdirlpllPCO,1 / <br />W INSIDE CITY LIMITS <br />x lG ���/ r M <br />Nebraska <br />Hall <br />Grand Island <br />14232 Pennsylvania Ave. <br />Yss ]j No <br />27 To the Desl of my k des81 occurred dme. dart n place and due to Me <br />causelsl staled. <br />10 IIA( .F leg., Wh.le BlaCM. American Indian. <br />11. ANCESTRY leg.. Italian, MeuCan German, 0, 1 <br />12 - MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE fn wile. grva marten name) <br />en-)lSoedtyl <br />Specify) <br />Czechoslovakian <br />NEVER DIVORCED <br />Bohumil Rott <br />29 DID TOBACCO 115E CONTRIBUTE TO THE DEATH? <br />White <br />30.b WAS CONSENT GRANTED? <br />Mq <br />� 14–NO <br />X ❑ YES 4–NO <br />14a 11SOAL OCCUPATION (Gave kind of work done dmkrg most <br />14b KIND OF BUSINFSS INDUSTRY <br />15. EDUCATION <br />(SpecM only highesl grade compbled) <br />Ekmenlsry a Secondary 10 -121 College 11 -4 or S. i <br />of work,ng rile, even it reeredl <br />32. RFGISTRAR <br />Administrator <br />Bois it_a__1 /Nursin Home <br />1 <br />IF; f ATHER - NAME FIRST MIDDLE LAST <br />n MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Joseph Bubenik <br />Rose Matovsky <br />16 WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />(Yes. no or unkJ h1 yen . give war and dates of serviced <br />Bohumil Rott <br />NO <br />191, INFORMANT MAILING ADDRESS (STREET OR RF D NO., CITY OR TOWN. STATE. ZIP( <br />4232 Pennsylvania Ave., Grand Is] -and, Nebraska 68803 <br />�2n dRALMER SIGNATURE E LICENSE NO <br />#1143 <br />21P METHOD OF DISPOSITION <br />21b DATE 21c. <br />CEMETERY OR CREMATORY - NAME <br />R• pru,c4,,Lt <br />�Bunal ❑Removal <br />A ri.l 24, 1997 <br />St. Paul Cemetery <br />22o FUNERAL HOME - NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livingston - Sondermann F.H. <br />❑Cremation ❑Donator <br />St. Paul, Nebraska <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP( <br />601 North Webb Road, Grand Island, Nebraska 68803 <br />!J �( MtUr I,a1V �t <br />PART <br />I <br />TO. OR AS A <br />Ib) <br />DUE TO. <br />I � I <br />I <br />I 1baNeen onset <br />I <br />i <br />I Interval between onset and death <br />I <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not relalod PART <br />PART PREGNANCY <br />111 IE FEMALE. WAS THERE A <br />IN THE PAST 3 MONTHS? <br />24 AUTOPSY <br />REF <br />25. WAS CASE ERRED TO MEDICAL <br />X EXAMINER OR CORONER( <br />(Ages 10 -541 Yes No <br />Yes No <br />Ves No <br />26a <br />26b. DATE OF INJURY /Mo.. Day Yr/ <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />El Accident El Undetermined <br />M <br />El Smcide Pending <br />28e. INJURY AT WORK <br />LLpp EE�p pp term, stress Iacbry <br />261 o8¢e eICRY <br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide lnvestigation <br />Vey ❑ No ❑ <br />buildings /SrN! <br />270 DATE OF DEATH /MO. Day Yr) <br />28a DATE SIGNED (MO.. DRY Yr.) <br />20b TIME OF DEATH <br />-a� - 9 <br />M <br />d <br />27b DATE SIGNED /Motl DRRay. Y!1 <br />27c TIME OFF DEATH <br />28C PRONOUNCED DEAD (MO. Day, Yr) <br />26d. PRONOUNCED DEAD /Flour) <br />2 <br />✓i wP V I (— <br />x lG ���/ r M <br />Z <br />M <br />K <br />4 <br />27 To the Desl of my k des81 occurred dme. dart n place and due to Me <br />causelsl staled. <br />28e. On Iha bade d sxaminelbn sMror klveatgation, m my opkaon dseBl oecurtad N <br />dme. date ant place and duo b the ceusslsl orated. <br />M � <br />nature and THb f�. t�� <br />S' end TMb <br />29 DID TOBACCO 115E CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />X ❑ ❑ UNKNOWN <br />� 14–NO <br />X ❑ YES 4–NO <br />R ❑ YES NO <br />YES l <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Pont) <br />x Dr. J.J. Cannella, M.D., 729 N. Custer, Grand Island, Ne. 68803 <br />32. RFGISTRAR <br />32b DATE FILED BY REGISTRAR (Md. Day. Yr.) <br />FOR VITAL STATISTICS USE ONLY <br />y e, <br />hereby certify, }:his to be a true and cor,�:.t c —pp of tI'e 0, th <br />Sate of <br />b y✓�( /i >✓ [qtr aZ��' ��l,,c � i ,_. Qa _ � <br />igned in my presence S <br />'-y <br />ftj. Df DeBdS <br />sa -p� <br />