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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF `HEALTH AND, WOMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAA-Rftbk .
<br />ti �
<br />DATE OF ISSUANCE f , �,
<br />16'1905842 nn S.TA EY OOE 'v
<br />eiS51s TANT STATE RE I5TI 4R .
<br />©EPARTM NT QF HEAL* AND
<br />LINCOLN, NEBRASKA PUMAN SER ICES'.. ; 17.
<br />10/15/2015
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HI1MAN'SEIPACES
<br />CERTIFICATE OF DEATH
<br />15 05921
<br />To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Norbert J Zoucha
<br />2."SRX t J• •'' U. FAbgt430
<br />MJl4 AA T ,,,'
<br />PtATN (Mo., Day, Yr.)
<br />"("ct1o�brer 5,--2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />tib. UNDER 1 YEAR
<br />5c.UNDEf{,1RDAY4-
<br />(6,,DATERP'BIRTH (Mo., Day, Yr.)
<br />Humphrey, Nebraska
<br />(Yrs.)
<br />81
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS."
<br />"'M"'''p
<br />January 3, 1934
<br />7. SOCIAL SECURITY NUMBER
<br />508-38-7268
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />Columbus Community Hospital
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Columbus 68602
<br />ad. COUNTY OF DEATH
<br />Platte
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Platte
<br />9c. CITY OR TOWN
<br />Columbus
<br />9d. STREET AND NUMBER
<br />1736 Minden Dr
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68601
<br />9g. INSIDE CITY LIMITS
<br />gl YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Betty Nienaber
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Michael Zoucha
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Leona Tworek
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 10/29/1954-10/18/1956
<br />14a. INFORMANT -NAME
<br />Betty Zoucha
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Dave Purcell
<br />16b. LICENSE NO.
<br />1075
<br />16c. DATE (Mo., Day, Yr.)
<br />October 8, 2015
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />All Saints Cemetery Columbus Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />McKown Funeral Home, Inc , 2922 13th Street, Columbus, Nebraska
<br />17b. Zip Code
<br />68601
<br />I
<br />CAUSE OF DEATH (See Instructions and examples)
<br />To be completed by: CERTIFIER
<br />15. PART I. Enter the chain of events -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac west,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Acute ARDS
<br />disease or condition resulting
<br />onset to death
<br />Hours
<br />in de) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Sequentially list conditions, if b)Acute Aspiration Pneumonia 1 Hours
<br />any, leading to the cause listed 1
<br />I
<br />on Lim a. DUE TO, OR AS A CONSEQUENCE OF: ' onset to death
<br />Enter the UNDERLYING CAUSE c) Acute Stroke With Dysphasia 1 Weeks
<br />(disease or injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LAST d) I
<br />1
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ 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 />® Natural 0 Homicide
<br />0 AccldeM 0 Pending Investigation
<br />21b. IF TRANSPORTATION'INJURV
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />❑ 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 0 Could not be determined
<br />0 Pedestrian
<br />❑ 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 />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />1
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 5, 2015
<br />2.g Z
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />„ =
<br />I;
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 12, 2015
<br />23c. TIME OF DEATH
<br />08:15 AM
<br />c
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />0
<br />E
<br />'2 a
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(.) stated. (Signature and Title)
<br />Nicole Anderson Ericksen, MD
<br />wz
<br />B C §
<br />'- 3 t
<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 TSIs)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN ® YES
<br />SSUE . • ATION BEEN CONSIDERED?
<br />■ NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 26a is NO 0 YES El NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Nicole Anderson Ericksen, MD, 4600 38th St., P.O. Box 1800, Coebraska, 68601
<br />28a. REGISTRAR'S SIGNATURE
<br />A- are--
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 14, 2015
<br />
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