|
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 DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11/9/2018
<br />LINCOLN, NEBRASKA
<br />2 0 1 8 0 7 6 2 5 RUSSELL
<br />ASSISTANT STATEE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Mary Jane Jarzynka
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 5, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a, AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Merrill, Wisconsin
<br />(Yrs.)
<br />78
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 19, 1940
<br />7. SOCIAL SECURITY NUMBER
<br />522-50-8476
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />CHI Health St. Francis
<br />0 ERwOutpatient 0 Decedent's Home
<br />o DOA 0 Other(Specify)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />118 W 12th St
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL
<br />❑`Married,
<br />STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />but separated 0 Widowed 0 Divorced 0 Unknown
<br />;1Ob. NAME OF SPOUSE (First, ; Middle, Last, Suffix) If wife, give maiden name
<br />Donald Jarzynka
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Theodore Dallman
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ella Paque
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Donald Jarzynka
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />October 9, 2018
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Westlawn Memorial Park Crematory Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home. 601 N. Webb Road, Grand Island. Nebraska
<br />17b, Zip Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examplesL
<br />t!. PART I. Enter the chain of events --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory a,rest, or Ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause: on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest
<br />disease or condition resulting
<br />onset to death
<br />24 Hours
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />seguenhaily listcmtddions, it b) Deep Vein Thrombosis /retroperitoneal Hemorrhage -
<br />any,leading to the cause fisted"
<br />on line a.
<br />onset to death
<br />48 Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C) Ground Level Fall
<br />(disease or injury that initiated
<br />onset to death
<br />48 Hours
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)Chronic Imbalance /ataxia
<br />onset to death
<br />Chronic
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Hypertension, Spinal Stenosis, Sleep Apnea, Anemia
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />® Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ® NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />0 Suicide Could not be determined
<br />0
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />October 3, 2018 ;,,-
<br />22b. TIME OF INJURY
<br />Unknown
<br />22c. PLACE OF INJURY -At home,
<br />Home
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d, INJURY AT WORK?
<br />❑res ®NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ground level fall in home
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />118 West 12th Street, Grand Island Nebraska 68801
<br />To be completed by'.
<br />MEDICAL CERTIFIER...
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 5, 2018
<br />To be completed by:::,
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 10, 2018
<br />23c. TIME OF DEATH
<br />01:27 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)l 24d. TIME PRONOUNCED DEAD
<br />23d. 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 />Ryan D. Crouch, DO
<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 />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ®NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION'BEEN CONSIDERED?
<br />❑YES ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand
<br />Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE��
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 16, 2018
<br />
|