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<br />WHEN THIS d "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 />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11/13/2017
<br />LINCOLN, NEBRASKA
<br />* i " 1 e d6ad� ; ^t: .074 �.t, r A srAtl! se, �.
<br />STATE OF NEBRASKA
<br />20 1708566
<br />xx,x r
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY S. UTOOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1-
<br />t{,.
<br />W
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Emmet Peter Jarzynka
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Papiin, Nebraski
<br />7. SOCIAL SECURITY NUMBER
<br />507 -36 =3528
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Wedgewood Care Center
<br />re
<br />p
<br />v =
<br />a 8c. cm; t OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND°NUMBER
<br />4263 North 80th Road
<br />4(ia. M ARETAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated; ❑ Widowed ❑ Divorced ❑ Unknown
<br />11.
<br />FATHERS-NAME (First, Middle, Last, Suffix)
<br />Anthonv Jarzynka
<br />13. EVER IN U.S.' ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or unit,) Yes 03/06/1947- 08/23/1948
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />® Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />117a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />I ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />Enter the UNDERLYING. CAUSE
<br />(disease or lnlury t{ at Imtrated - ::
<br />ttle events re §tilting . n death)
<br />LAST:::
<br />20. IF FEMALE: :>`
<br />❑. Not pregnant within past year
<br />❑ Pregnant at time of death
<br />Not pregnant,;bu pregnant within 42 days of death
<br />❑ Nkt pregnant b pregnant 4a days to 1 year before death
<br />❑ OttanOwn if pregnant
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />P
<br />v
<br />. I(i1JURY AT:WQRK?
<br />YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />November 1; 2017
<br />8a, •REGISTRAR'.$ SIGNATURE
<br />9b. COUNTY
<br />Hall
<br />22b. TIME OF INJURY
<br />23b. DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH
<br />Novemeer 2017 02:36 Aivi
<br />3d. To the best of my knowledge, death Occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Steven Huser MD
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />88
<br />16a. EMBALMER - SIGNATURE
<br />Chris McCoy
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />CITY/TOWN
<br />5b. UNOER 1 YEAR
<br />MOS.
<br />9c, CITY OR TOWN
<br />Cairo
<br />5. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES ❑ NO 0 PROBABLY ❑ UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Steven Husen, MD 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />8'a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER © Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />Hospice Facility
<br />DAYS
<br />HOURS
<br />8d. COUNTY OF DEATH
<br />Ha!I
<br />9e. APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Dorothy Rose Behrens
<br />CAUSE OF DEATH (_See instructions and examples)
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />12. MOTHER'S -NAME (First, Middle,
<br />1 Antonia Badura
<br />14a. INFORMANT -NAME
<br />Dorothy Rose Jarzynka
<br />MINS.
<br />9f. ZIP CODE
<br />68824
<br />16b LICENSE NO.
<br />1191
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Dementia
<br />21b. IF TRANSPORTATION INJURY
<br />© Driver/Operator
<br />❑ Passenger
<br />pedestrian
<br />Other
<br />STATE
<br />245. DATE SIGNED (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ❑ NO
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 1, 2017
<br />6. DATE OF BIRTH (MO.,Da
<br />December 5, 1928
<br />Suffix) If wife, give maiden name
<br />Maiden Surname)
<br />November 6, 2017
<br />9g. INSIDE CITY LIMITS`
<br />❑ YES ® NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />November 4, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY /TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17ts Zip Code
<br />68801
<br />ta. PART 1. Enter theivt.+ain of events- - diseases, injuries, or complications that directly caused the death. 00 NOT en termMai eve nts such as cardiac arrest,
<br />respiratory awegt, ar ventdcul5r fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only One cause on a line Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardiopulmonary Arrest
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Acute
<br />ir�:deae
<br />Se(1ueittially lief corid lions, if ::
<br />any, IeadingtO h
<br />te <ausellsted'
<br />on line a _ _. ..: •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Kidney Disease
<br />onset to dea ::
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Benign Prostatic Hypertrophy
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Tobacco Abuse
<br />onset to death:
<br />Years
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ELI NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Y tY Z
<br />3
<br />0
<br />8!°
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES Q' NO
<br />eon
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />1
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