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<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 />5/25/2017
<br />LINCOLN, NEBRASKA
<br />201907514
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Lorraine M Matousek
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />Elba, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-34-8118
<br />84
<br />2. SEX
<br />Female
<br />5b. UNDER 1 YEAR 5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />0IDOA
<br />FACILITY -NAME (If not Institution, give street and number)
<br />Madonna Rehabilitation Hospital LTC
<br />re ▪ 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />o Lincoln 68506
<br />9a. RESIDENCE -STATE
<br />1" Nebraska
<br />LL 9d. STREET AND NUMBER
<br />1133 S. Greenwich St
<br />ISa. MARITAL STATUS AT:T1ME OF DEATH ® Married 0 Never Married
<br />❑Married, but separated ❑ Widowed 0 Divorced ❑ Unknown
<br />ti
<br />9b. COUNTY
<br />Hall
<br />1. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Hubert O'Neill
<br />HOURS
<br />MINS.
<br />17 06484
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 16, 2017
<br />6. DATE OF BIRTH (Mo.Day,
<br />November 13,
<br />OTHER El Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />932
<br />0 Hospice Facility
<br />9g. INSIDE CITY LLMITS
<br />II YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden names
<br />Norbert , L Matousek
<br />a 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yee, NO, or Unk.) No
<br />1--
<br />15. METHOD OF: DISPOSITION
<br />® Burial ❑ Donation
<br />0 Cremation 0 Entombment
<br />:❑, RemOVel Q Other (Specify)
<br />112. MOTHER'S -NAME (First, Middle,
<br />Anna Ambrose
<br />14a. INFORMANT -NAME
<br />Norbert Matousek
<br />16a. EMBALMER -SIGNATURE
<br />Paul A. Seger
<br />16b. LICENSE NO.
<br />1425
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />1$, PARI' I. $Bier th?4hain of events- -diseases, injuries, or complications -that directly caused
<br />1'44°1'1" arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBRE
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Cardiopulmonary Failure
<br />disease or condition resuaing
<br />In death) ... DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially iisi conditions, if b) Sepsis
<br />any, leading to the muse listed,;
<br />On linea
<br />Enter the UNDERLYING CAUSE
<br />(diseaenorinjuryt#tat Initiated
<br />IM events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Pneumonia
<br />Maiden Surname)
<br />he death, DO' NOT enter terminal events such as cardiac arrest,
<br />TATE. Fatter only one cause ion a line. Add additional lines if necessary.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />May 22, 2017
<br />STATE
<br />Nebraska
<br />17b, Zip: Code
<br />68801
<br />APPROXIMATE INTERVAL..
<br />onset to death
<br />Weeks
<br />onset to death
<br />Weeks
<br />onset to death
<br />Weeks
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Carebral Vascular Accident
<br />onset to death
<br />Months
<br />18. PART 11. OTHER SIGNIFIC
<br />ANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />20. IF FEMALE:
<br />❑ Not pregnantYFthinpasryear
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of Wath
<br />❑ Not pregnant.:bdt pregnant 43 days to 1 year before Wath
<br />❑•Unknown if prgnant Within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d..INJURY ATWORK?
<br />❑YES El NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide ❑ Could riot be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />lather(SPecih)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ❑ No
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />rvt2,• 1S, 2017
<br />CITY/TOWN
<br />25b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />FFa' u z May 19, 2017 06:25 PM
<br />3d. To the bast of my knowledge, death occurred at the time, date and place
<br />8
<br />O C
<br />and due to the cause(s) stated. (Signature and Title)
<br />Kristina C. Hardy, APRN
<br />26. DID TOBACCO USEGONTRIBUTE TO THE DEATH?
<br />0 YES NO ❑ PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />I 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />z
<br />g 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />o.az
<br />��s=o
<br />Y W Z
<br />A � O
<br />U
<br />3
<br />tae. On the basis of examination and/or Investigation, In my opinion Wath occurred at
<br />the time, date and place and dire to the cause(s) stated. (Signature and Tae)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN' CONSIDERED?
<br />❑ YES i7 e
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kristina C. Hardy, APRN, 3900 Pine Lake Rd, Ste 5, Lincoln, Nebraska, 16
<br />Sa.REGISTRAfTS SIGNA DRE
<br />28b. WAS CONSENT GRANTED? '
<br />Not Applicable if 26a is NO 0 YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (MO., Day, Yr.)'
<br />May 22, 2017
<br />
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