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ittv ,; v deatitt610 ';; atosUA, STATE OF NEBRASKA o dy l s*tv'.`'`.i�' a te tot E4 . w uJ U E 0 v 2 WHEN ! THIS : COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 p 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Thomas Ruzicka 4, CITYAND STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH DATE OF ISSUANCE 8/22/2017 LINCOLN, NEBRASKA Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -74 -5319 b. FACILITY -NAME (If not Institution, give street and number) 919 L'V. 7tn St ee 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand island 68801 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 919 W. 7th Street 108. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married but Separated; >❑ Widowed ® Divorced ❑ Unknown 11. FATHER'S -NAME (First; Middle, Last, Suffix) Louis Frank Ruzicka 13, EVER IN U.S, ARMED FORCES? Give dates of service if Yes. (Yes, No or Link.) NO 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal .0 Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)4; Curran Funeral Chapel, 3005 S. Locust St.. Grand Island, Nebraska IMMEDIATE CAUSE (Final disease or condition resulting in.death) Sequentially list conditions, it any, leading to the cause listed On line a. - -- DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Idlsea$e Or injury that initiated ...... t ...... n ..._. ttie av0pts resuRidg::in death) .AST 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Net pregnant but pregnant within 42 days of death Net Pregnant. l?ut Pregnant 43 days to 1 year before death 0 Unknewnif pregnam within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) z ed. INJURY AT WORK? ❑YES ❑NO 9 v Z $ c 28a. REGISTRAR'S SIGNATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Not Embalmed 22f. LOCATION OF INJURY STREET 8, NUMBER, APT.NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services DUE TO, OR AS A CONSEQUENCE OF: 13) Chronic Alcohol Abuse DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED DATE OF DEATH (Mo., Day, Yr.) Auqust't 20 Z3b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH AugUSt 16, 2017 05:45 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s).stated. (Signature and Title) ary:Se M0 CAUSE OF DEATH (See instructions and examples) 21a. MANNER OF DEATH Natural ❑ HOmieide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES ❑ NO ❑PROBABLY ❑ UNKNOWN ❑ YES 2 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 201706726 5a, AGE - Last Birthday (Yrs.) 64 14a. INFORMANT-NAME John Ruzicka MOS. 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ERA7utpatient ❑ LOA 9c. CITY OR TOWN Grand Island' 5b.: UNDER 1 YEAR DAYS CITY/TOWN ❑ Passenger ❑ Pedestrian Other (Specify) 9e. APT. NO. STANLEY S. 'COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 6b. LICENSE NO. Gibbon 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC 2 Decedent's Home ❑ Other (Scecify) 8d, COUNTY OF DEATH Hall 9f. ZIP CODE 68801 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Mary Ann Kocian to :PART t. Enter thetlxain Of el/Mitt-diseases, injuries, or complications -that directly caused the death. DO NOT entarterminal events such as cardiac arrest, respiratory arrestor ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. • IMMEDIATE CAUSE: a) Primary Hepatocellular Cancer 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Severe Malnutntion, Chronic Obstructive Pulmonary Disease STATE id Gel July 13, 1953 onset to ctOath 20 Years onset to death 28b. DATE FILED BY REGISTRAI August 16, 2017 3. DATE OF DEATH.(Mo., Day, Yr.) August 14, 2017 6. DATE OF BIRTH (Mo., Day, W.)', ❑ Hospice Facility 9g. INSIDE CITY LIMITS` ® YES ❑ NO 14b. RELATIONSHIP TQ DECEDENT Brother • 16c. DATE (Mo., Day, Yr.) August 15, 2017 STATE Nebraska 17b. Zip. Code 68801 APPROXIMATEINTERVAL: onset to death 6 Months 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑' YES 2 NO 21b� TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PI"RFORMED? 0 Dover/Operator ❑ 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) ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH. 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 Z rc O z g z o O O 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 ❑ NO (Mo, Day, Yr.)