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vitmega mo: STATE OF NEBRASKA 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 11/1312018 LINCOLN, NEBRASKA 2 018 0 7 4 3 A DSEPRUSSELL FOSLER ARTMENT OF T STATEEALTH REGISTRAR AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1814249 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. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ernest R Bydalek 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) October 25, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Ashton, Nebraska (Yrs.) 92 MOS. DAYS HOURS MINS. March 21, 1926 7. SOCIAL SECURITY NUMBER 506-26-9783 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center 0 ER/Outpatient ❑Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a.RESIDENCE-STATE Nebraska 9b. COUNTY Hall Sc.CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1218 W. Division 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS E YES ❑ NO 19a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married ❑.Married, but separated ; E Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Leona Heil 11. FATHER'S -NAME (First, Middle, Last, Suffix) Sylvester Bydalek 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Agnes Maciejewski 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) No 14a. INFORMANT -NAME James Bydalek 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Patricia R. Curran 16b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) November 3, 2018 ❑ Cremation ❑Entombment El Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. 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 respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional tines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest disease or condition resulting onset to death Hours in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially Bat cOAditions, if a b) Dementia any, leading to the cause listed on line a. onset to death Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Atrial Fibrillation (disease or injury that initiated onset to death Years the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 20. IF FEMALE: = 9 Not pregnant within past year 9 Pregnant at time of death❑ 21a. MANNER OF DEATH E Natural ❑ Homicide 0 Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 0 Suicide Could not be determined 9TO 9 Pedestrian 0 Other(Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE Tobe completed by. MEDICAL CERTIFIER. ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) October 25 2018 To be completed by CORONER'S PHYSICIAN of COUNTY ATTORNEY. ONLY 245. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 29, 2018 23c. TIME OF DEATH 03:40 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Kenneth Vette), MD 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO 0 PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED By REGISTRAR (Mo., Day, Yr.) November 8, 2018