|
,• O f1711ik,,,,,,AdtfCkodIsh,aaan AIaKCCIlIt,,,
<br />,�3tEA4M�WdJtx xaatt1991tII1.Itt9F53
<br />uulPrn� s yZy9'(tilYlttivv... trnrgynllt. ::_:
<br />•ettt ri
<br />yl C((t Mr1tf r"
<br />+•
<br />1FIt9a� arts
<br />WHEN 1 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 />2/1/2021
<br />LINCOLN, NEBRASKA
<br />202101765
<br />Ir
<br />„V- lfr. I ,12,4}. z.i,�� .1),
<br />SARAH BOHNENKAMP
<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 />21 01041
<br />O
<br />a
<br />E
<br />a
<br />*
<br />9
<br />'o
<br />5
<br />1. DECEDEN'1"$'NAME (First, Middle, Last, Suffix)
<br />Michael Allen Vanicek
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Pao., Day, Yr.) [.
<br />January 19, 2021 . .
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Schuyler, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-72-0308
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILI7Y-HAME+1#'not institution, give street and number)
<br />1830 Howard Court
<br />65
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />December21, 1955
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />D Hospice Facility
<br />9d. $T'REET AND NUMBER
<br />1830 Howard Court
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />814. INSIDE CITY LIMITS<
<br />lJ YES D NO <:
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Rhonda Denise Rathje
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle,
<br />LeROy Vanicek Ardeth ` Kral
<br />Maiden Surname)
<br />13. EVER IN 11,8ARMED FORCES? Give dates of service N Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Rhonda Denise Vanicek
<br />14b. RELATIONSHIP TO DECEDENT'
<br />Spouse
<br />15. METHOD QF DISPOSITION
<br />D' Burial 0 Donation
<br />Cremation ❑Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />January 20, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<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 sweet,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Glioma In Brain
<br />IMMEDIATE CAUSE (Einar
<br />disease or condition resulting
<br />In death)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause lasted
<br />on line a.
<br />Este! the.UNDERLYIN6 CMSE
<br />(disuse or injury'that initiated
<br />the events resulting In death)
<br />LAST
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onsetito death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<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 ka NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past War
<br />0 Pregmm at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />D Unknown if pregnant within the past War
<br />228. DATE OF INJURY (Mo Day, Yr.)
<br />21a. MANNER OF DEATH
<br />El Natural D Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />0 Driver/Operator
<br />0 Passenger
<br />❑'Pedestrian
<br />D Other (Specify)
<br />INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 511 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES ❑NO
<br />of
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />yr 22r. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />p3' January 19, 2021
<br />2 Et 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />2 g u o January 19, 2021 02:02 AM
<br />t�!
<br />0.
<br />o.
<br />CITY/TOWN
<br />STATE EJP cope
<br />gad. TO the beet of my knowledge, death occurred at the time, data and place
<br />and due to the cause(a) stated. (Signature and Title)
<br />Travis S. Hageman, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion Wath OCeurreddt
<br />the time, date and place and due to the causes) stated. (Signature *MINN)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />El YES IR1NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES
<br />DNO
<br />21,;NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />January 27, 2021
<br />
|