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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE . DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />4 A
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />STANLEY COOPE
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />DATE OF ISSUANCE
<br />SEP 132011
<br />LINCOLN, NEBRASKA
<br />it# PART I. Enter the chain bT events- dieeeeea. injuries, or Complications- that direc tly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular tlbrilfatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on.aline. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMED1ATECAUSE(Fwl
<br />deem orecialionrat . DUE TO, OR AS A CON OUENCE OF:
<br />2R IFFEMALE:
<br />"Net past
<br />O Pregnant at time of death
<br />0 Not pregnant, but pageant within 42 days of death
<br />Q Netptegr colt, btdptegnam 43 days to I yeerbetore death
<br />n Unkrewn 3tpregnant within the past year
<br />22a DATE GF INJURY (Mo., Dey,Yr.)
<br />22d. INJURY AT WORK?
<br />C/ YES tilorro
<br />...... .
<br />LOCATION OF .STREET & NUMBER. APT NO.
<br />DUE TO, OR ASACONSEQUENCEOF: 4
<br />(a) c r -\IOG
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />R SIGNIFICANT CONDITIONS- Conrntions contributing to the death but not resulting in the tin
<br />22b. TIME OF INJURY
<br />m
<br />22e: DESCRIBE HOW INJURY OCCURRED,
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />4)0to.er 29, 2005
<br />Gtgtt tT X005
<br />21 a. MANNER OF DEATH
<br />Oi atural CI Homicide
<br />215 WERE AUTOPSY FINDINGS AVA�LE
<br />COMPLETE CAUSE OF DEATH?
<br />IN N
<br />Cl YES 0
<br />22c. PLACE OF INJURY -At home, farm, street. factory, ollice building, construction sits, etc. (Specify)
<br />0 Es:elde n C ^1ld sal Le Jerarnitned
<br />ing canoe given in PART I.
<br />24b. I F TRANSPORTATION INJURY
<br />tar/river /Operator
<br />13Pessenger
<br />( Pedestrian
<br />la Other (Specify)
<br />}
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OFDEATH
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2 LO
<br />onset to death
<br />oruet to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />13 YES (3 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />D YES UTarO
<br />23d. To the best of my VI
<br />Cal
<br />Street Grand
<br />24d. TIME PRONOUNCEDDEAD
<br />Rl
<br />t. DECEDENT'S -NAME (First,
<br />Nary
<br />ITY AND STATSOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Boelus, Nebraska
<br />7. SOCIALSECURrTYNUMBER
<br />505 -30 -6838
<br />9b
<br />Wedgewood Care Center
<br />CIT( OR TOWN OF DEATH (Include Zip Code)
<br />Crr -anti Ts1 a nti
<br />i s RESIDENCE- STATE
<br />Nebraska
<br />SQ STREFTAND NUMBER
<br />1. FATHE R'S- NAME .(First,.
<br />vb.n
<br />15. METHOD OF DISPOSITION
<br />ISOurial G1 Donation
<br />m Q
<br />QCtertum Entombment
<br />❑ Removal ❑ Other (Specify)
<br />:28a REGIS T{(AR'S 5) y(eTURE
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH
<br />Middle,
<br />Ann
<br />AME. (If not institution, give street and number)
<br />9b. COUNTY
<br />Hall
<br />214 W. 16th Street
<br />1Ea. MARITAL STATUSAT TIME OF DEATH a Married ❑ Never Married
<br />0 Married, but separated U Widowed R Divorced U Unknown
<br />Middle,
<br />9. EVER IN 0,5. ARMED .FORCES? Give dates of service It yes.
<br />(Yes, no, or unk.) > NO
<br />16d. CEMETERY, OREMAT. RY OR OTHER LOCATION
<br />ERALHOME NAME AND MAIL NO ADDRESS (Street, City orTown, Slate
<br />.p 1 Funeral Home 1123 West 2nd
<br />e(a) elated. (Stgnatu a and Title) • •
<br />5 DIOTOBAC0O... NTRIBUTE TO THE DEATH?
<br />0 YES ( 1O Q PROBABLY U UNKNOWN
<br />Last,
<br />Cyboron
<br />201706520
<br />Les),
<br />Plambeck
<br />a. Aa ۥLast Birthday
<br />(*era) '
<br />77
<br />1 Ob. NAME OF SPOUSE' (First,
<br />Suns)
<br />14a. INFORMANT -NAME
<br />Donald Plambeck
<br />Grand Island. City Cemetery
<br />26e. HAS ORGAN OR TISSUE DONATION
<br />56, UNDER 1 YEAR
<br />MOS. DAYS
<br />at. CITY ORTOWN
<br />Grand Island
<br />Se. APT.
<br />Donald Plambeck
<br />12. MOTHER'S -NAME (First,
<br />Leona
<br />16b, LICENSE NO.
<br />/2 . 40
<br />CITY (TOWN
<br />EN CONSIDERED?
<br />2. SEX
<br />Female
<br />NO
<br />Sc. UNDER I DAY
<br />HOURS
<br />MINS
<br />Sri. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE
<br />68801
<br />die, Last, Suffix) If wife give maiden name.
<br />Island, Nebraska
<br />Middle.
<br />05 12171
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 29, 2005
<br />6. DATE OF BIRTH (Mo., Day, Yr,
<br />May 20, 1928
<br />8a. PLACE OF DEATH
<br />HOSPITAL! > Q Inpatient. OTHER a Nursing Home/LTC ❑ Hospice Faci6
<br />U'ERIOutpetieot • ❑ Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />27, NAME:TITLE AND - ADDRESS OFCERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Dr. Ryan Crouch. .. 800 N Alpb= Ave. Grand Island. Nebraska
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />NOV 3 .2005
<br />9g. INSIDECITY UNITS
<br />a YES 0
<br />Maiden Surname)
<br />Czapla
<br />14b. REL ATIONSHIP TO DECEO I
<br />Husband
<br />16c. DATE (Ma., Day, "
<br />Nev 2, 2005
<br />STATE
<br />Grand Island Nebraska
<br />i lb. Zip Code
<br />68801
<br />LlATE GNFD (M Y 23o.TIMEOF DEATH t s 24c- PRONOUNCED DEAD (Mo., Day. Yr.)
<br />5:25
<br />edge, . -alit occur ed at the lime, date and place i 0 24e. On the basis of examination and/or Investigation, In my opinion death occurred at
<br />the time, date and place and dueto the meets) stated. (Signature endYdle) •
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable it 26a Is NO 0. YES 6:1
<br />68803
<br />
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