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<br />STATE OF NEBRASKA
<br />.� •nt .r , v' �'.r
<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 DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />06/12/2019
<br />LINCOLN, NEBRASKA
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<br />201904072
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />16 20
<br />1., DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Onial Nouzovsky
<br />1 SEX
<br />Male
<br />S(AMERc. UER t DAY
<br />2. DATE OF DEATH iWo..OAyYr.)
<br />January 21, 2016
<br />6, DATE OF BIRTN (Mo,, Day, Yr.)
<br />October 20, 1936
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />3a. AGE•LeW Birthday' St. UNDER t YEAR
<br />Mettick County, Nebraska
<br />(Yrs,1 .' MOS.
<br />79 i
<br />DAYS
<br />HOURS
<br />MINS.
<br />2. SOCIAL. SECURITY NUMBER
<br />506.508231
<br />aa. PLACE Or CN -ATN
<br />11OSPrTAL• i Inpatient OMR: ] taunting Hone:LTC OH000)a,FaoIttty
<br />0 CRIDutpatent 0 Deudenl't Home
<br />0DOA [701karrSPecRTu(
<br />Sb. FACILITY -MANE (If nal institution, give street and number)
<br />CHI ; Health St. Francis
<br />6o,. OTT OR TOWN OF DEATH (Rictods Zip Code) 1 Rd. COUNTY or DEATH
<br />Grand island 68803 j bail
<br />Sa, RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Sc. CITY OR TCAVN
<br />Grand Island
<br />99, STREET AND NUMBER
<br />507 East Capital Avenue
<br />Se- APT. NO.
<br />9f. ZIP CODE
<br />L. (38801
<br />Sg. INSIDE LY'TY UNITS
<br />g1 yea ©s"'
<br />10s. MARITAL STATUS AT Tier OF DEATH IDMarrlen 0 Nsvar tsaniediteb. NAME OF SPOUSE (Fitt, Middle. Last. Sonia) S e.fo, glint ntaldet roma.
<br />0 Marriott, bun separated 0 Wktowed 0 Divorced 0 Unknown
<br />) 1 Jeanie .�tandCjuiSt
<br />11. FATHER'S -NAME (First, Middle, Last. duffle!
<br />Joseph MOUTONSky
<br />12. MOTHER'S -NAME (FL•et, Middle, Mahan Surname)
<br />Rose Klepedko
<br />10, EVER VEILS ARMED FORCES? Cava darts of tendo. R Yee. i :4a. INFORMANT OJA1,1E
<br />(Yes, No, or Unk.) No ' Jeanie Nouzovsky
<br />14h. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />I6: METHOD OF DISPOSITION
<br />MewedDDanede'
<br />16a. EAI:. • E ER -S ,N TUR,?
<br />/i L 1 y' f,,
<br />1Eb. LICENSE NO.
<br />f� t/(;/
<br />E (Mo.. y, Yr.)
<br />tRc. DATLa
<br />January 26, 2016
<br />fcaaem Mn' O6momhrnnr1
<br />04.,,.,....1 04.,,.,....1 Ddtru,f6p.cit,l
<br />t6d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWNCITY/TOWNSTATE
<br />Wegt)OWn Cemetery Grand (stand Nebraska
<br />173, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, EIata)
<br />Ap{el Funeral Home, 14,23 W 2nd, Grand Island, Nebraska
<br />176, Zip Code
<br />88801
<br />CAUSE OF DEATH (See instructions and examples)
<br />fa. PART I. Ertel' ilea onamor,nema .. AM.. s, a:iinn, or catnpltrad.rne- Mit dtreoliy rimed inn aban:. DO NOT skint earn.. am0Ma oval er mole, aunt. APPROXIMATE IN AVAL
<br />rnnlrmM,Y oral. or reot'tc urer nMiOnort.,*Mout nhtw0,a da, niters,. DO NOY 4EhnEV;Att !no only one r; mon on r lino. Anil a641Nnnai ikon If nocaasesy
<br />IMMEDIATE CAUSE,
<br />IMMEDIATE CAUSE (Find aa
<br />deems 00 comiltion resuidng at 'i.:t. r).Le-.s ,.,,.ar J,': ,r_ Y
<br />in ansms
<br />onset to death
<br />FADE_ TO, OR AS A CONSEQUENCE OF onset to death
<br />Spuertdatty list amid/lions. II bi I
<br />Guy, toadied to tiro cause Sated
<br />.et i:its o. DUE TO, OR AS A CONSEDUENCE OF:onset to drain
<br />Enter the UNDERLYING CAUSE El
<br />(dxosse or injury that initialed
<br />the events r.suiting ut dsaU,( DUE TO, OR AS A CONSEQUENCE Cec.
<br />LAST
<br />4)
<br />onset to death
<br />YE. PART IL OTHER SIGNIFICANT CONDITIONS-ComLtions contrtb ting to the death But not resulting in the ondertying cause glyon in PART I.
<br />1S. WAS MEDICAL EXAMINER
<br />OR CORONER. memo/
<br />El YES NO
<br />20. IF FEMALE:
<br />0 Not prognotd within past your
<br />(3Prsunant at: time of dealt,
<br />° Not prognent, but pregnant within 42 days of death
<br />0Not pregnant, but pregnant 42 days to 1 year before dealt,
<br />°Unknown If pregnant within Lha post year
<br />.,„, MANNER OF DEATH
<br />j,?},Ninn.J ID Homicide
<br />0 AerlIdern 0 Prating tnvasdgadret
<br />a Sulchne ['3 Could not be dwerminsd
<br />21h. IF TRANSPORTATION INJURY}}} 210. WASr-AM AUTOPSY PERFORMED?.
<br />0 Driver/OperatorD YES 1QIkR!
<br />0 Patsengar i 714 WERE AUTOPSY FINDINGS AVASAiM.E.
<br />0 Pedsstdon ) TO COMPLETE CAUSE OF DEATH?
<br />r
<br />l] Other (Spenity((3YES 0 NO
<br />ESa. DATE OF INJURY IMP,. Day, Yr.)
<br />22b. TIME. OF INJURY
<br />to
<br />22a. PLACE OF INJURY -At home, tern, strael factory, office building, constnutlon site, etc, ISpsci(y`,
<br />22d. INJURY AT WORK?
<br />0 YES 0 INC
<br />22e. DESCRIBE MOW INJURY OCCURRED
<br />?21, LOCATION' OF INJUR - STREET A NU'✓E.1R, APT. EU. CITY TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Ida., Day, Yr,)
<br />.b'6 j ,i':.. 1 /I b
<br />a to
<br />2 O
<br />zyr
<br />n 6,n
<br />o a
<br />t' O
<br />244. DATE AtONED (Ma.. Dam. Yr.; j 241). TIDE OF MAT II
<br />I m
<br />7.Ic. PRONOUNCED DEAD (Mo., Day, `T.) • 24d. TIME PRONOUNCED OPJID
<br />{ m
<br />1 lab DATE WINED (t/ Day, Yr.)
<br />s
<br />E } /1,).5 -/it,
<br />23e. TIME OF DEATH
<br />}:,ri um0a
<br />24e. On rho haat el examination ander investigation, In my opinion deaf. clammed
<br />at the time, dot* and place and dim to tea ew,tc(e) stated, (Signature end Tette)
<br />u 0. e3 23d. To the best of my knowledge, death occurred nt Lha (lone, date and plata.w
<br />. p and due to the Ituse� stated. (Sigsvt,r. o and T!Ne)
<br />it
<br />N” i t r 7'�.f�
<br />26, DID TOBACCO V5C (:vO,,N,/tRtOUTE TO THE DEATH? 26a, HAS ORGAN OR TISSUEDONATIONSEEN CONSIDERED?
<br />0 IES ' 0 NO PROBARI. Y [] UNKNOWN 0 YES titND
<br />pO?
<br />UP
<br />26b. AS CONSENT GRANTED
<br />Not Applicable N 293 It NO 0 YES
<br />27, NAME, TITLE AND ADDRESS�OF CER i-fF1ER (Type Or Print)
<br />Shane J. Burr M.n, 938 N. Reward 0105, Czarrd--sttLanr3, NE h8403
<br />2aa. REGISTRAR'S SIGNET URE
<br />a: r l ,r' -,.
<br />26b. DATE Frl ED BY REGISTRAR (M0. Day. Yr.)
<br />FEB 1 20%f
<br />Orn
<br />C3 1
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