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<br />%• STATE OF NEBRASKA
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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 le
<br />I
<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 />DATE OF ISSUANCE
<br />2/28/2019
<br />202100117
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Barbara Jean Dvorak
<br />4, CITY: AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St. Paul, Nebraska
<br />5a. AGE , Last Birthday
<br />(Yrs.)
<br />59
<br />5b; UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 24, 2019
<br />6. DATE OF BIRTH
<br />Mc Day Yr -j:
<br />September 3, 4959
<br />7. SOCIAL SECURITY NUMBER
<br />505-90-6105
<br />8b. FACII.ITY.NAME (If not Institutlon, give street and number)
<br />1174 Eagle Road
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑',ER/Outpatient
<br />© DOA
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />St. Paul 68.873
<br />8d. COUNTY OF DEATH
<br />Howard
<br />9a.: RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Howard
<br />9e. CITY OR TOWN;
<br />St. Paul
<br />9d. STREET AND'NUMBER
<br />1174 Eagle Road
<br />9e. APT. NO.
<br />9L ZIP CODE
<br />68873
<br />9g. INSIDE CITY LIMITS"
<br />❑ YES ® NO
<br />10a, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 'g 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First,
<br />Roger Ray > Dvorak.
<br />Middle, Last, Suffix) N wife, give maiden name
<br />re filed with the coni
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Arthur Holt
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Marlene Joan Svoboda
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />Removal ❑ Other(Specify)
<br />14a. INFORMANT -NAME
<br />Roger Ray Dvorak
<br />16a. EMBALMER -SIGNATURE
<br />Todd M Peters
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Elmwood Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Peters Funeral Home. 302 Second Street. PO Box 181, St. Paul, Nebraska
<br />16b. LICENSE NO.
<br />1078
<br />CITY / TOWN
<br />St. Paul
<br />CAUSE OF DEATH (See instructions and examples)
<br />16. PARTI, Fitter the;ebaln bt edpru3--dissasas, injuries, or complications -that directly caused the death. 00 NOT enter 'terming events such as cardiac arrest,
<br />refpiretoay arrest, or ventrictlai fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter: only one cause on a line, Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Sudden Cardiac Death
<br />disease or condition resulting
<br />n death)
<br />Sequenilaly list corlditbM, If
<br />any, leading to the cause Listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(diseai8 of injury th YA initiated
<br />the events retiree* 14 death(
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Myeloma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Hypertension
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE:
<br />® Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Not pregnant,nut pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknowtt a pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES ONO
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />211), IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />❑ Pade:bun
<br />Ottrarf3pecIfy(
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />March 1, 2019
<br />STATE
<br />Nebraska
<br />17b, Ztp Code
<br />68873
<br />APPROXIMATE INTERVAL ..
<br />onset to death
<br />Immediate
<br />onset to death
<br />onset to death:
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ONO
<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 />23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23e. TIME OF DEATH
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO: USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />February 25, 2019
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />February 24. 2019
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />Approx. 02:00 AM
<br />24d. TIME PRONOUNCED DEAD
<br />08:00 AM
<br />24e. On tiro basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and pace and due to the cause(s) stated. (Signature and Tele)
<br />David T. Schroeder, Howard County Attomev
<br />26a. HAS ORGAN OR TISSUE DONATION BEENCONSIDERED?
<br />❑ YES 7 +
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />David T. Schroeder, Howard County Attorney, 612 Indian St., Ste 3, St. Paul, Nebraska, 68873
<br />204. REGIS
<br />R'S SIGNATURE•
<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 />February 25, 2019
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