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IIAtt 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 DATE OF ISSUANCE 11/13/2017 LINCOLN, NEBRASKA RVAL' 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Emmet Peter Jarzynka 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Paplin, Nebraska 7. SOCIAL SECURITY NUMBER 507 -36 -3528 . FACILITY -NAME (if not Institution, give street and number) Wedgewood Care Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND " NUMBER 4263 North 80th Road 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 1Ob. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden na Married, butseparated ❑ Widowed ❑ Divorced ❑ Unknown Dorothy Rose Behrens 11. FATHER'S•NAME (First, Middle, Last, Suffix) Anthony Jarzynka 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Vas, No, or Unit ) YeS .03/06/1947- 08/23/1948 15. METHODOFGISPOSiTION ® Burial ❑ Donation 0 Cremation ❑ Entombment Q Removal ::❑ our (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) ADfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska . PART I. Enter they chain of events- -diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory arrest of Ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest disease or condition resulting in deaths Sequentially )ist ctihtlitlOna, if :i any,:leadingte the cause Iiefed on line a. Enter the UNDERLYING CAUSE ' disease or tnjury that initiated he events resbltlny n death) LAST 16a. EMBALMER- SIGNATURE Chris McCoy DUE TO, OR AS A CONSEQUENCE OF: b) Chronic Kidney Disease DUE TO, OR AS A CONSEQUENCE OF: c) Benign Prostatic Hypertrophy DUE TO, OR AS A CONSEQUENCE OF: d)Tobacco Abuse 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Dementia 20. IF FEMALE ❑ Not pregnantvnthin past year ❑ Pregnant at time of death ❑ Notpregnadt, but pragnant 42 days of death ❑ Nvt pregna�rt, but pragnanf 43 days to 1 year before death ❑ t)nkmrwn if pregnan wftt4n the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. 1FIJURY AT WORK? YES ❑ NO 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. 23a DATE dF DEATH (Mo., Day, Yr.) November 1, 2017 23b. DATE SIGNE'D (Mo., Day, Yr.) November2, 2017 9b, COUNTY Hall 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services 22b. TIME OF INJURY 1 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 02:36 AM 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) even Husen;, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 28a, REGISTRAR'S SIGNATURE STATE OF NEBRASKA 201802355 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 5a. AGE - Last! Birthday (Yrs.) 88 14a. INFORMANT -NAME Dorothy Rose Jarzynka 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient © DOA 9c. CITYOR TOWN Cairo CAUSE OF DEATH See instructions and exam • les 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY/TOWN s Z 8 P. O ; Q 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven Husen, MD„ 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 O 5b. UNDER 1 YEAR MOS. DAYS i 12. MOTHER'S -NAME {First, Antonia Badura STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e. APT. NO. 2. SEX Male 8d. COUNTY OF DEATH Hall b. LICENSE NO. 1191 5c. UNDER 1 DAY HOURS Gibbon OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) CITY/TOWN 9f. ZIP CODE 68824 214 IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) Middle, Maiden Surname) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO Cafe MINS. 24C. PRONOUNCED DEAD (Mo., Day, Yr.) 6. DATE OF BIRTH 24b. TIME OF DEATH 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) 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 6, 2017 3. DATE OF DEATH (Mo., Day, Yr.) November 1, 2017 December 5, 1928 onset to de ath ' Years onset to death Years onset to death Years (Mo., Day, Yr.) 9g. INSIDE CITY LIMITS` ❑ YES ® NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) November 4, 2017 STATE Nebraska 17b, Z'tp Code 68801 APPROXIMATE INT onset to death Acute 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED ? ❑ YES ® NO 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 21d. WERE AUTOPSY FINDI;NGs AVAILABL TO COMPLETE CAUSE OF DEATH ?::. ❑YES ❑ND