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<br />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 />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORYFOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />3/26/2018
<br />LINCOLN, NEBRASKA
<br />201802270
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY`` COOPER
<br />ASSISTA n STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />8
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Andrew NMI Necas Jr
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Clarkson, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507 -26 -9245
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND NUMBER
<br />2410 W. Phoenix Ave
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑Married, but Separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle,
<br />Andrew NMI Necas Sr
<br />Last, Suffix)
<br />1 12. MOTHERS-NAME (First, Middle,
<br />Anna Klatt
<br />Maiden Surname)
<br />13. EVER IN 1.0. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No: or Unk.) No
<br />15, METHOD CIF DISPOSITION
<br />Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />20. IF FEMALE:
<br />❑ Not pregnant within pa st year
<br />❑ P regnant at time of death
<br />❑ Not pregnant but p regnant wit 42 da of death
<br />0 Not pre Pregnant 43 da t 1 y e ar re death
<br />❑ Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d INJURY AT WORK.?
<br />❑YES ❑NO
<br />I 28a. REGISTRAR
<br />3a. DATE OF DEATH (Mo., Day, Yr.)
<br />Juiv 13, 2010
<br />b. DATE Slf3NED (Mo., Day, Yr.)
<br />25, DID TOBACCO US i' ONTRIBUTE TO THE DEATH?
<br />LI YES El NO ❑ PROBABLY ❑ UNKNOWN
<br />Se. AGE - Last Birthday
<br />(Yrs.)
<br />83
<br />MOS.
<br />14a. INFORMANT -NAME
<br />Phyllis Joanne Necas
<br />16a. EMBALMER - SIGNATURE
<br />Laurie D. Sheffield
<br />CAUSE OF DEATH .See instructions and examples)
<br />18. PART!, Enter the chain of events injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrestor ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause; on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />22b. TIME OF INJURY
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />23c. TIME OF DEATH
<br />10: PM
<br />Q z July 15, 2010
<br />. 72 0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />• Travis S. Hageman, MD
<br />S SIGNATURE A I
<br />6b. UNDER 1 YEAR
<br />DAYS
<br />HOURS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />O DOA
<br />OTHER ® Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES El NO
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MINS.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />91. ZIP CODE
<br />68803
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Phyllis Joanne Brink
<br />16b. LICENSE NO.
<br />1397
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17a, FUNERAL HONIE NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island` Nebraska
<br />IMMEDIATE CAUSE:
<br />a) Metabolic Encephalopathy
<br />APPROXIMATE(NTERVAL
<br />onset todeath
<br />Months
<br />in death);.,_
<br />Segyemialty list eondnions, it f
<br />any, eedirig tosite Lausehated'
<br />on f(ne a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Liver Failure
<br />Enter the UNDERLYING CAUSE
<br />(diseaEeor tnjwy t7tat tmttatad
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Cirrhosis
<br />onset to death
<br />the:eyents'resgiti
<br />LAST
<br />m dea
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES: 10 NO
<br />21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED
<br />❑ Driver /Operator
<br />❑ YES IX1 NO
<br />❑ Passenger
<br />❑ Pedestrian
<br />Q tither (Specify) DEATH
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Severe Spinal Stenosis
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 13, 2010
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />4, 1927
<br />9g. INSIDE CITY LIMITS:
<br />1 YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />July 17, 2010
<br />1 ?b. Zip Code
<br />68801
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF ?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, fans, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<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 causes) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Travis S, .Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28b. DATE FILED BY REGISTRAR (MO„ Day, Yr,)
<br />July 19, 2010
<br />
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