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DATE OF ISSUANCE 02/01/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S.SOOPER ASSISTANT STATE' REGISTRAR QEPARTh9 ' OF HEALTH 4ND HUMAN SERVICES`` 201605408 • 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. 16 00447 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Arnold Alvin Jelinek 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Farwell, Nebraska 7. SOCIAL SECURITY NUMBER 505 -36 -3925 8b. FACILITY -NAME (If not Institution, give street and number) Valley Ccl.inty Health System 8c. CITY OR TOWN OF DEATH (Include Zip Code) Ord 68862 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 111 East 21st Street 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 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 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑ NO 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Randall O'Brien 22b. TIME OF INJURY 23a. DATE OF DEATH (Mo., Day, Yr.) W January 20, 2016 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH z January 21, 2016 I 03:04 PM .1O t 23d. To the best of my knowledge, death occurred at the time, date and place c and due to the cause(s) stated. (Signature and Title) Hilary B. Miller, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Prin Hilary B. Miller, MD, 2707 L Street, Ord, Nebraska, 68862 5a. AGE - Last Birthday (Yrs.) 88 21a. MANNER OF DEATH 0 Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 1 28a. REGISTRAR'S SIGNATURE /Jt A- 5b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ERlOutpatient ID DOA 9e. APT. NO. 126a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES ❑ NO t 2. SEX Male Sc. UNDER 1 DAY HOURS I 24a. DATE SIGNED (Ma., cay, Yr.) z $ = Q H Z W z O gz 'o .5 MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Valley 9c. CITY OR TOWN Grand Island 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 9f. ZIP CODE 68801 14a. INFORMANT -NAME I Ruth Jelinek 16b. LICENSE NO. 0953 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) tit. 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, 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) Presumed Catastrophic Cardiopulmonary Event disease or condition resulting in death) 3. DATE OF DEATH (Mo., Day, Yr.) January 20, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) May 12, 1927 ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name I Ruth Scherzberg 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Jelinek 12. MOTHER'S -NAME (First, Middle, Alice V Novak Maiden Surname) 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) January 25, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY / TOWN STATE Grand Island Nebraska 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death 3 Hours Sequentially list conditions, if any, leading to the cause listed n line a DUE TO, OR AS A CONSEQUENCE OF: b)Supra therapeutic on coumadin, HTN, Atrial Fibrillation, Pulmonary Edema, Pneumonia onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c ) (disease or injury that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II, OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b. TIME CF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 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(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 29, 2016 i