200008006 - Laserfiche WebLink

Browse

Sc CITY TOWN OR LOCATION OF DEATH = �� 8d 111110E CITY LIMITS 8e. COUNTY OF DEATH rn Grand Island T Yes M No ❑ Hall REGNANCY IN THE PAST 3 MONTHS't 9a RESIDENCE - STATE n z o �� D o a. W M N �' co 9e WSIDE CITY LIMITS N d U Undetermined I Grand Island CD 6880 © ❑ PC N O CZ CITY OR TOWN STATE Homicide ID❑ Investigation Yes No ❑ O C 11. ANCESTRY le g. Italian. Mexican. German, etc) 12. ®MARRIED ❑WIDOWED 13 NAME OF SPOUSE n/ wife. give maiden name) etc llSoeuryl White ISoeutyl American NEVER DIVORCED MARRIE CD Ct) 141 KIND OF BUSINESS INDUSTRY c grade eompletedl of working lde, even it retired) Child Care O ID - College 11 40, 5 -i a a1 1L 4 16 FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Harold en Darleen Dalgarn WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND_MU41-i4N SERVICES i9a INFORMANT - NAME _ SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL - 4 - -WITH n n THE NEBRASKA HEALTH AND H(JMAN SERVICES SYSTEM, VITAL STATIC I IS \ Zeleski THE LEGAL DEPOSITORY FOR VITAL RECORDS 7. DATE OF ISSUANCE_- 20000800 \ JUL 7 2000 assnNra-Tis€: , LINCOLN, NEBRASKA HEALTH AND'IIU f STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN 3UgVrj;S F$ _PORT VITAL STATISTICS - - CERT_IFICATE OF DEATH' =�= DECEDENT -NAME F7R$T MIDDLE LAST 2 SEX ?' 3. DATE OF DEATH MO,(, Dav Year) _ Sithay Ellen Zeleski Female` July 2, 2000 4. CITY AND STATE OF BIRTH Irf not in US.A.. name country! 5a. AGE Last Birthday UNDER 1 YEAR UNDER 1 DAY 16 . DATE OF BIRTH /Mon #. Day Year/ 5b Mos DAYS SC HOURS Mws Sutherland, Nebraska 'Y"' 48 January 28, 1952 7 SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH - - - - -- : Inpanenl OTHER Nursing Home 505 -74- 4612 HOSPITAL © ' —. - -- —_ ❑ fib FACILITY - Name fit not institution, give sheet and number) ❑ ER Outpatient ❑ Residence Saint Francis Medical Center ❑ DOA ❑ OtherlSpeclty, Sc CITY TOWN OR LOCATION OF DEATH 8d 111110E CITY LIMITS 8e. COUNTY OF DEATH OTHER SIGNIFICANT CQNDITIONS - Conditions contributing to the death but not related Grand Island 25 WAS CASE REFERRED TO MEDICAL Yes M No ❑ Hall REGNANCY IN THE PAST 3 MONTHS't 9a RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION Ves No I�/I 9d STREET AND NUMBER /including Zip Code' T26t• LATE OF INJURY ;MO Day. Yrl 26c HOUR OF INJURY 9e WSIDE CITY LIMITS Nebraska Hall U Undetermined I Grand Island 4354 Cambridge Rd., 6880 © ❑ 261 PLACE OF INJURY At home. far, . street factory T26g LOCATION STREET OR R.F D NO CITY OR TOWN STATE Homicide ID❑ Investigation Yes No ❑ Yes No 10 RACE (e.g., White. Black American Indian 11. ANCESTRY le g. Italian. Mexican. German, etc) 12. ®MARRIED ❑WIDOWED 13 NAME OF SPOUSE n/ wife. give maiden name) etc llSoeuryl White ISoeutyl American NEVER DIVORCED MARRIE Timothy R. Zeleski 14a 'USUAL OCCUPATION (Give kindot work done during most 141 KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only highest - grade eompletedl of working lde, even it retired) Child Care Elementary9r Secondary 10 12) - College 11 40, 5 -i Daycare Provider 1L 4 16 FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Harold Barger Darleen Dalgarn 18 WAS DECEASED EVER IN U S ARMED FORCES? i9a INFORMANT - NAME _ (Yes . no or unk I III yes give war and dates of servicesl No Timothy R. Zeleski IYti mrVnmhrvl —orlU hU "n IJI H—I Vr1 M1lU —, III IT — i— I e I t. 1I11 4354 Cambridge oad, Grand Island, NE 68803 20 MIMMER - SIGNATURE 8 LICENSE NO 1 0 9 2 21 a METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME 'i — ' ❑Burial ❑Removal j July 6, 2000 Paxton Cemetery. L HOME NAME' 210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Curran Funeral Chapel ❑cremation ❑Donato, Paxton NE 22b. FUNERAL HOME ADDRESS (STREET OR FLY 0 NO CITY OR TOWN STATE. ZIP1 X005 South Locust Street, Grand Island, NE 68801 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ial Ib). AND Ml Interval between onset and dealt, PART p al '1�1 rL2 y F� iC 511, � c k /Z 4 ,, mss. DUE TO, OR AS A CONSEQUENCE OF Interval between onset and deem IN DUE TO OR AS A CONSEGiIE between onset and dealr Ic) OTHER SIGNIFICANT CQNDITIONS - Conditions contributing to the death but not related PART 111 IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL PART REGNANCY IN THE PAST 3 MONTHS't E %AMINER OR CORONER' II I;AgeS 10 -541 Yes ❑ No Yes ❑ No Ves No I�/I 26a T26t• LATE OF INJURY ;MO Day. Yrl 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED - -�J— Accident U Undetermined I M S— de F1 Pending 26e INJURY AT WORK 261 PLACE OF INJURY At home. far, . street factory T26g LOCATION STREET OR R.F D NO CITY OR TOWN STATE Homicide ID❑ Investigation Yes No ❑ o ice budding. etc 'SpecIty) z 27a DATE OF DEATH /MO Day Yr./ 28a DATE SIGNED (Mo.. Day Yr f 28b TIME OF DEATH ' 27b DATE SIGNED (Mo. Day Yr I 2It TIME OF DEATH 7 > 28c PRONOUNCED DEAD IMo. Day. Yr) 28d PRONOUNCED DEAD (Hour) M g 27d To the best of my knowledge oeam 9ccured al the d e nd olace antl due 10 the o 0 28e On the basis of examination and or investigation, In my opinion death occurred at y causes) stated. / /} /�^� the lime, date and place and due to the causelsl stated. r (Signature and Tale) / IS, nature and Title 0, 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH 0 a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 10 1, WAS CONSENT GRANTED' ❑ YES [!r NO ❑ UNKNOWN ❑ YES NO ❑ YES IN NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNT" ATTORNEYi :Type or P-1) Dr. Gary L. Settje M.D., 2116 W. Faidley #400, Grand Island, NE 68803 32a REGISTRAR 32b DATE FILED BY REGISTRAR (MO.. Day. Yr.) JUL 6 2000 LEGAL: LOT THREE (3) BISHOP HEIGHTS SECOND SUBDIVISION, HALL COUNTY, NEBRASKA