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<br />WHEN TI'IIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE rA 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 />1/13/2020
<br />UINCOLN, NEBRASKA
<br />5
<br />0
<br />d
<br />20200216
<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 />CERTIFICATE OF DEATH
<br />1, DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donald James Ruzicka
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />alk, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-46-1907
<br />5a. AGE Last Birthday,
<br />(Yrs.)
<br />80
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Wedgewood Care Center
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />ER/Outpatient
<br />0 00A
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 16, 2019
<br />6. DATE OF BIRTH (Mo., D.
<br />Yr.)
<br />June 18, 1939
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) I8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a.:RESIDENCE4TATE '>
<br />Nebraska;
<br />9d. STREET AND NUMBER
<br />322 W. Stolley Park Rd.
<br />9b. COUNTY
<br />Hall
<br />9c. CITYOR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS'
<br />® YES ❑ NO
<br />10a. MARITAL, STATUS, AT TIME OF DEATH 0 Married 0 Never Married
<br />• { Married, put separated 0 Widowed ® Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />It. FATHER'$JIAME (First, Middle, Last, Suffix)
<br />Joseph Ruzicka
<br />12, MOTHER'S -NAME (First,
<br />Helen Janky
<br />Middle, Malden Surname)
<br />13. EVER IN U,S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />15. METHOD OF DISPOSITION
<br />fiEj Burial 0 Donation
<br />❑ Cremation ❑ Entombment
<br />Removal ;< 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Daniel Joseph Ruzicka
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />178- FUNERAL NOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island; Nebraska
<br />16b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Grand Island
<br />a:. CAUSE OF DEATH (See, instructions and examples)
<br />5 15.2%811. Enter the chain of events -diseases, injuries, or complications -that directly caused tate death. DO NOT enter tsrminet events such as cardiac arrest,
<br />tespkatory &feet, M ventt't ular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one taut* on a line. Add additional lines a necessary.
<br />IMMEDIATE y -r -
<br />CAUSE:
<br />IMMEDIATE CAUSE (Final a) M e!od enias!(c Syndrome
<br />y..,
<br />E disease or condition resulting
<br />in dentin)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Ssyuentiaaylie[Eonditlens,+r b)
<br />aititi:040Ipptottic'eapeit Sated-
<br />on finee
<br />m
<br />Enter the UNDERLYING CAUSE
<br />• (difeeit otinjutypratlnititse4
<br />m
<br />the events rasedang in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />14b. RELATIQNSH#P TO DECEDENT
<br />Son •
<br />16c. DATE (Ma,, Day, Yr,)
<br />December 21, 2019
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to Meath
<br />Months
<br />onset to death
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Bipolar Disorder, Hypertension, Chronic obstructive pulmonary disease, Osteoarthritis
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES NO
<br />v
<br />.2
<br />.a
<br />a
<br />O
<br />M 123a. DATE OF DEATH (Mo., Day, Yr.)
<br />°s # Decenc�er' 16, 2019
<br />I At y. 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />S IV z December 31. 2019 06:19 AM
<br />0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />ell I
<br />- and due to -the causation stated. (Signature and TitM)
<br />a `- /I Jay C. Anderson, MD
<br />20. IF FEMALES.
<br />0 Not pregnant within past year
<br />0 Pregnant et time of Math
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, Dut ;Regnant 43 days to 1 year before Math
<br />❑ Unknown If stagnant vbthin the pest year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22dINJURY A r WORit?
<br />❑YES QNrj
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑' Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑
<br />Other (specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />c3 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 />CITY/TOWN
<br />128x. REGISTRAR'S SIGNATURE
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES I NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a, DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />ZIP CODE
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)1 24d. TIME PRONOUNCED DEAD::
<br />24e. On the ',osis of e•aninetlo. in :ron'gation, In my opinion death occurred at
<br />the time, date and place and due to the nemesis) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Jay C. Ander$on, MD, 729 North Custer Avenue, Grand (stand, Nebraska, 68803
<br />�=�--
<br />26b. WAS CONSENT GRANTED?`
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 8, 2020
<br />
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