|
�r
<br />.\j WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEA4 IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE .OAfIF -WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TIST/GS SEIRiIV �Yl�IItJS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE " ( j`r fU
<br />�+ �+ Alf3 COOPER
<br />MAY 2 4 2000 ASSISTANT SWE- REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HtIM M SERVICES SYSTEM -
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE9VE -ES FINANCE AND"SUPP0RT
<br />VITAL STATISTICS
<br />CERTIFICATE. OF DFATi-I
<br />F1 OF(,EDENT NAME FIRST MIDDLE LAST
<br />�v
<br />S DATE OF DEATH ,MOmh Dav ✓earl
<br />Bohumil Rott
<br />Male
<br />May 16, 2000
<br />4 CITY AND STATE OF BIRTH nl not m U.S A. name country)
<br />Sa. AGE Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />--
<br />6. DATE OF BIRTH /Month. DaY. ✓earl
<br />St. Paul, Nebraska
<br />IYrsl I
<br />85
<br />5b. MOS DAYS
<br />N
<br />April 6, 1915
<br />7 SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH -— - --
<br />505 -68 -4399
<br />HOSPITAL a Inpatient --OTHER ❑ Nu(51ngHCme
<br />C:
<br />8b FACILITY Name pinolmstlfufion, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other Sde I,!
<br />Bc CITY TOWN OR LOCATION OF DEATH
<br />o
<br />o
<br />Grand Isl_and _
<br />rn
<br />1 Hall
<br />9a R NCE -STATE
<br />9b COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER /Including Zlp Cl-U(Jo 3 qe INSIDE CITY t (MIT
<br />Nebraska
<br />Hall
<br />4
<br />CD
<br />10 RACE (e g.. White Black American Indian
<br />R s
<br />12. ❑ MARRIED ® WIDOWED
<br />13 NAME OF SPOUSE W wde grve maiden nan,el
<br />etc)ISoeoty)
<br />White
<br />(Soeotyl
<br />Czech
<br />-10
<br />Hope Bartunek (Dec)
<br />Z
<br />N
<br />o /working rile, even drenredt
<br />Owner/operator
<br />Elementary or Secondary 10 -121 College n a of ti
<br />Meat Market 3 Years
<br />16 FATHER -NAME FIRST MIDDLE LAST t
<br />7 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Joseph Rott Sr.
<br />Margaret Ptacnik
<br />18 WAS DECEASED
<br />r—
<br />IYes. nn or unk)
<br />iI! yes give wa1 and date, OI ee.Vicea)
<br />No
<br />-- - - - - -- Bonnie Hummel
<br />_
<br />I9b INFORMANT MAILING ADDRESS !STREET OR R.F D '10.. CITY OR TOWN. STATE ZIP( -- - - "-
<br />724 S. Blaine Grand Island, Nebraska 68803
<br />_
<br />?0 E _R SIG
<br />/ 21a METHOD OF DISPOSITION _u1b OATF i1 21c CEMETERYORCREMAI')Rr NAME
<br />)AT,
<br />SV �° ®Bunal ❑Rempval May 19, 2000 1 St. Paul Cemetery
<br />22a FUNERAL ME - NAME 21d CEMETERY OR CREMATORY LOCATION CITY DP TOWN STA)!.
<br />Livin ston- Sondermann F.H. El Cremation El Donator St. Paul, Nebraska
<br />12b FUNERAL HOME ADDRESS (STREET OR R.F.D NO G7v OR TOWN. STATE. ZIP) - -- - - - - -- - - - - -- - -
<br />6_01 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />_
<br />23 IMME E CAUSE (ENTER ONLY ONE CAUSE PER LINE FDA lal (b). AND (of l interval between onset and
<br />.loam
<br />PART
<br />x I f1�L1
<br />lal
<br />DUE 70. OR AS CO�NSSEEO�UEENCE OF Interval between d onset an ream
<br />/AA
<br />\
<br />DUE TO. OR AS A CONSEOUENCE OF Interval between once,
<br />Icl
<br />NLj
<br />T
<br />C:
<br />N
<br />PREGNANCY
<br />IN THE PAST 3 MONTHS'/
<br />' EXAMINER CORONFR',
<br />�A'E
<br />_
<br />Ages I0-541 Yes No
<br />Yes No
<br />-
<br />26b DATE OF INJURY /Mo Day. Yy
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />® Accident ❑ Undoi,l red
<br />5 -8 -00
<br />0300 M
<br />y
<br />LJ Subtle ❑ Pending
<br />26e INJURY AT WORK
<br />261 PLACE OF INJURY - At home farm . street factory
<br />'"oe bustling. etc tSpecily/
<br />r_
<br />269 LOCATION STREET OR R.F.D. NO I"I iiR TOWN
<br />Homicide lnvesigauon
<br />--
<br />Yes[:] No X❑
<br />nursing home
<br />3119 W. Faidley, Grand Island, NE
<br />IM
<br />:)
<br />28a DATE SIGNED /MO. Day Yrl
<br />\
<br />C=)
<br />U
<br />i
<br />M
<br />271, DATE SIGNED IMI c Day. Y i
<br />U)
<br />28c PRONOUNCED DEAD tMO. Day, Yr)
<br />280 PRONOUNCED DEAD (Noun
<br />M
<br />� z
<br />8' go
<br />u
<br />° Q o.0
<br />AV/
<br />21 On the basis of examination and or investigation. in my opinion oeavl occurred a1
<br />the lime, date and place and due to the causel5l staled.
<br />'^
<br />fV�
<br />(Signature and Title) ► (�r� '�� L • � � Q
<br />ISI nature and Title) ►
<br />29 DID TOBACCO USE CONT�R/I TO THE D ATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b
<br />WAS CONSENT GRANTED'
<br />IBUTE
<br />"- ❑ YES ]( NO ❑ UNKNOWN )'
<br />O
<br />❑ vES
<br />O
<br />O
<br />�r
<br />.\j WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEA4 IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE .OAfIF -WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TIST/GS SEIRiIV �Yl�IItJS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE " ( j`r fU
<br />�+ �+ Alf3 COOPER
<br />MAY 2 4 2000 ASSISTANT SWE- REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HtIM M SERVICES SYSTEM -
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE9VE -ES FINANCE AND"SUPP0RT
<br />VITAL STATISTICS
<br />CERTIFICATE. OF DFATi-I
<br />F1 OF(,EDENT NAME FIRST MIDDLE LAST
<br />2 SEX
<br />S DATE OF DEATH ,MOmh Dav ✓earl
<br />Bohumil Rott
<br />Male
<br />May 16, 2000
<br />4 CITY AND STATE OF BIRTH nl not m U.S A. name country)
<br />Sa. AGE Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />--
<br />6. DATE OF BIRTH /Month. DaY. ✓earl
<br />St. Paul, Nebraska
<br />IYrsl I
<br />85
<br />5b. MOS DAYS
<br />5, HOURS MINIS
<br />April 6, 1915
<br />7 SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH -— - --
<br />505 -68 -4399
<br />HOSPITAL a Inpatient --OTHER ❑ Nu(51ngHCme
<br />❑ ER Outpa^ent ❑ Residence
<br />8b FACILITY Name pinolmstlfufion, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other Sde I,!
<br />Bc CITY TOWN OR LOCATION OF DEATH
<br />Btl INSIDE CITY LIMITS
<br />8e COUNTY OF DEATH - - --
<br />Grand Isl_and _
<br />Yes ® No ❑
<br />1 Hall
<br />9a R NCE -STATE
<br />9b COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER /Including Zlp Cl-U(Jo 3 qe INSIDE CITY t (MIT
<br />Nebraska
<br />Hall
<br />Grand Island
<br />4232 Pennsylvania Ave. Yes ® No C
<br />10 RACE (e g.. White Black American Indian
<br />11. ANCESTRY le g.. Italian. Mexican. German, etc)
<br />12. ❑ MARRIED ® WIDOWED
<br />13 NAME OF SPOUSE W wde grve maiden nan,el
<br />etc)ISoeoty)
<br />White
<br />(Soeotyl
<br />Czech
<br />NEVER ORCED
<br />MARRIED DIV
<br />Hope Bartunek (Dec)
<br />14a USUAL OCCUPATION IGrve kindot work dome during most 14b
<br />KIND OF BUSINESS INDUSTRY 15 EDUCATION IS peo ty only in IT 1 grade comp1 led)
<br />o /working rile, even drenredt
<br />Owner/operator
<br />Elementary or Secondary 10 -121 College n a of ti
<br />Meat Market 3 Years
<br />16 FATHER -NAME FIRST MIDDLE LAST t
<br />7 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Joseph Rott Sr.
<br />Margaret Ptacnik
<br />18 WAS DECEASED
<br />EVER IN u S ARMED FORCES? I 19a. INFORMANT NAME
<br />IYes. nn or unk)
<br />iI! yes give wa1 and date, OI ee.Vicea)
<br />No
<br />-- - - - - -- Bonnie Hummel
<br />_
<br />I9b INFORMANT MAILING ADDRESS !STREET OR R.F D '10.. CITY OR TOWN. STATE ZIP( -- - - "-
<br />724 S. Blaine Grand Island, Nebraska 68803
<br />_
<br />?0 E _R SIG
<br />/ 21a METHOD OF DISPOSITION _u1b OATF i1 21c CEMETERYORCREMAI')Rr NAME
<br />)AT,
<br />SV �° ®Bunal ❑Rempval May 19, 2000 1 St. Paul Cemetery
<br />22a FUNERAL ME - NAME 21d CEMETERY OR CREMATORY LOCATION CITY DP TOWN STA)!.
<br />Livin ston- Sondermann F.H. El Cremation El Donator St. Paul, Nebraska
<br />12b FUNERAL HOME ADDRESS (STREET OR R.F.D NO G7v OR TOWN. STATE. ZIP) - -- - - - - -- - - - - -- - -
<br />6_01 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />_
<br />23 IMME E CAUSE (ENTER ONLY ONE CAUSE PER LINE FDA lal (b). AND (of l interval between onset and
<br />.loam
<br />PART
<br />x I f1�L1
<br />lal
<br />DUE 70. OR AS CO�NSSEEO�UEENCE OF Interval between d onset an ream
<br />/AA
<br />\
<br />DUE TO. OR AS A CONSEOUENCE OF Interval between once,
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS Conditions contributing 10 the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25 WAS (,ASE FERR ED TO MEDICAL
<br />PREGNANCY
<br />IN THE PAST 3 MONTHS'/
<br />' EXAMINER CORONFR',
<br />�A'E
<br />_
<br />Ages I0-541 Yes No
<br />Yes No
<br />-
<br />26b DATE OF INJURY /Mo Day. Yy
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />® Accident ❑ Undoi,l red
<br />5 -8 -00
<br />0300 M
<br />fell at nursing home
<br />LJ Subtle ❑ Pending
<br />26e INJURY AT WORK
<br />261 PLACE OF INJURY - At home farm . street factory
<br />'"oe bustling. etc tSpecily/
<br />r_
<br />269 LOCATION STREET OR R.F.D. NO I"I iiR TOWN
<br />Homicide lnvesigauon
<br />--
<br />Yes[:] No X❑
<br />nursing home
<br />3119 W. Faidley, Grand Island, NE
<br />27a. DATE OF DEATH IMO. Day YrJ
<br />28a DATE SIGNED /MO. Day Yrl
<br />-
<br />28b TIME OF DEATH
<br />U
<br />i
<br />M
<br />271, DATE SIGNED IMI c Day. Y i
<br />27c TIME OF DEATH
<br />28c PRONOUNCED DEAD tMO. Day, Yr)
<br />280 PRONOUNCED DEAD (Noun
<br />M
<br />� z
<br />8' go
<br />u
<br />° Q o.0
<br />27d io the best of my owled h oecurred time. date and la a and due to the
<br />'�CauSelsi stated
<br />21 On the basis of examination and or investigation. in my opinion oeavl occurred a1
<br />the lime, date and place and due to the causel5l staled.
<br />fV�
<br />(Signature and Title) ► (�r� '�� L • � � Q
<br />ISI nature and Title) ►
<br />29 DID TOBACCO USE CONT�R/I TO THE D ATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b
<br />WAS CONSENT GRANTED'
<br />IBUTE
<br />"- ❑ YES ]( NO ❑ UNKNOWN )'
<br />❑ YES ':P�_NO 'Y
<br />❑ vES
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEVI _l Type or Prrnt/
<br />Jo%r\ C� th %%1•�J. -c/ /V✓►
<br />/j ♦ _ I Jm UA It IlLt- fly HtU11I HAH win Lily I/
<br />
|