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1. DECEDENT - NAME FIRST MIDDLE LAST Rosyln Louise Stepanek 2. SEX Female 3. DATE OF DEATH /Month Day. Year) April 6, 2003 4. CITY AND STATE OF BIRTH (if not in U.S.A.. name country) Grand Island, Nebraska 5a. AGE - Last Birthday ) 66 R 1 YEAR UNDER 1 DAY DATE OF BIRTH (Month. Day. Year) July 29, 1936 . Sb M MINS. . . Sc HOURS 7. SOCIAL SECURTIY NUMBER 507-36-2984 8a. PLACE OF DEATH HOSPITAL: Inpatient OTHER ❑ Nursing Home ❑ ER Outpatient ❑ Residence ❑ DOA ❑ Other (Specdvi 8b. FACILITY - Name (lint institution, give street and number/ Howard County Community Hospital To be Completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 8c. CITY. TOWN OR LOCATION OF DEATH 18d. St. Paul, Nebraska INSIDE CITY LIMITS :ea nom. No I 8e. COUNTY OF DEATH Howard 90 RESIDENCE - STATE Nebraska 9b. COUNTY • Howard 9c. CITY. TOWN OH LOCATION St. Paul 9d. STHEE1 AND NUMMBEF (including Zip Code) 949 Hardy Road 9e iNsi0E CITY OMITS Yes ❑ No 10. RACE - (e.g., White. Black. American Indian. etc.) (Specify( White 11. ANCESTRY (e.g.. Italian. Mexican, German, etc) (Specify) Danish /German t2. MARRIED ❑ WIDOWED NEVER DIVORCED ❑ MARRIED ❑ 13 NAME OF SPOUSE (If ode. give maven name) Eddie Stepanek Ma. USUAL OCCUPATION (Give kind of work done during most of working life, even if retired) Housewife 14b KIND OF BUSINESS INDUSTRY Own .Home 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary (0 -12) College 11 - or 5'I 10 16. FATHER - NAME FIRST MIDDLE LAST •(dec) Walter T. Olsen 1 MOTHER FIRST MIDDLE MAIDEN SURNAME (dec) Meta Grosch 18. WAS DECEASED (Yes no. or unk.) No EVER IN U.S. ARMED FORCES? of yes. give war and dates of services) 19a. INFORMANT - NAME Eddie Stepanek OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART p G N „, L II R$L 1 �,L Frq- - i -v' PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? (Ages 10 -54) ! Yes ❑ No ❑ 24 AUTOPSY Yes ❑ No N 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? Yes ❑ No !� 26a. IN Accident in Undetermined Suicide In Pending Homicide Investigation 266.. DATE OF INJURY (Mo.. Day. Yr.) 26c. HOUR OF INJURY M 26d. DESCRIBE HOW INJURY OCCURRED 260 INJURY AT WORK Yes ❑ No ❑ 261 PLACE OF INJURY - At home, farm. street factory office building, etc. (Specify) 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE To be Completed by Attending PHYSICIAN ONLY 27a. DATE OF DEATH (Mn . Day. Yr.) F F" \ r1\ 1 p d.oi 0 To be Completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 28a. DATE SIGNED (Mo.. Day. Yr.) 28b TIME OF DEATH M 28c, PRONOUNCED DEAD (Mo.. Day, Yr.) 28d. PRONOUNCED DEAD (Hour) 27b. DATE SIGNED (Mo.. Day. Yr.) 4-- _l - 0 3 27c. TIME OF DEATH ' - ao M 28e. On the basis of examination andor investigation, in my opinion death occurred at the time, date and place and Use to the causes stated. r (Signature and Title) ► 27d. To the best of my knowledge. d th oc, as eGa ghe time, date and place and due to the causels) stated. / (Signature and Title) O. ! 1 ^^ - - sf -------- - 29. DID TOBACCO USE CONTRIBUTE T HE DEATH? ❑ YES NO ❑ UNKNOWN 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES g NO 30.b WAS CONSENT GRANTED? ❑ YES ❑ NO WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, _W HICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF 4/15/2003 E 20170t712 A way s. COOPER ASSISTANT STATE LINCOLN, NEBRASKA HEALTH AND HUMAN SER VICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH HUMAN SERVICES FINA3ICE AND SUPPORT 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 949 Hardy Road St. Paul, I J'1 rJ" �^t v✓.+t- •J AY V ""'� - . - VV 21a. METHOD OF DISPOSITION Burial 11 Removal Cremation ❑ Donation 21k. DATE Apr 10, 2003 214. CEMETERY OR CREMATORY LO y 20. EMBALMER - SIGNATURE at LICENSE NO. Y.LNERAL HOME NAME 22a. Jacobsen - Greenway Funeral Home 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO, CITY OR TOWN. STATE, ZIP) 411 "O" Street St. Paul, NE 68873 23. IMMEDIATE CAUSE PART nL .' I . (al ' fiTO lL % (LI /t7.S7 DUE TO, OR AS A CONSEOUENC OF (b) C Vft DUE TO, OR AS A CONSEQUENCE OF (C) (ENTER ONLY ONE CAUSE PER LINE FOR la). lb), AND )c) 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type or Print) a u - e rn .O f 0, Box -► Gs 32a. REGISTRAR VITAL STATISTICS 03 04096 CERTIFICATE OF DEATH NE 68873 200306933 21c. CEMETERY OR CREMATORY NAME Elmwood Cemeter CATION CITY OR TOWN ' STATE St. Paul Nebraska 320 DATE FILED BY REGISTRAR (Mo.. Day. Yr./ APR 1 4 2003 Interval between onset and death Interval between onset and death Interval between onset and death �� Y� ( 13