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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 />6/17/2021
<br />LINCOLN, NEBRASKA
<br />202105"x20
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<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 />1 07682
<br />Pursuant to section 30-24:13, demands for notice which may affect the estate of the deceased are tiled with the county court ha the county where the decedent resided at the time of death. ; I
<br />-
<br />- 1, DECEDEN'T'S -NAME (First, Middle, Last, Suffix)
<br />Charlotte Josephine Rerucha
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, YT.)'
<br />June 8, 2021
<br />4. CM AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />6b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />Dwight, Nebraska
<br />(Yrs.)
<br />84
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />May 26, 1937
<br />7. SOCIAL SECURITY NUMBER
<br />505-42-8731
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC © Hospice Faclltty
<br />8b. FACILITY-NAME(If not Institution, give street and number)
<br />Tiffany Square, Care Center
<br />0 ER/outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68803
<br />( 8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d STREET AND NUMBER
<br />706 Joehnck Rd.
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g.INSIDE
<br />a YES
<br />Cwt. Limits
<br />❑ NO
<br />10a. MARITAL' STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) 11 wife, give maiden name
<br />Adrian L Rerucha
<br />11, FATHER'S•NAME (First, Middle, Last, Suffix)
<br />Joseph John Sypal
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)I
<br />Helen Matulka
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Pamela S Bengtson
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />J stinal ❑ponati°"
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16b. LICENSE NO.
<br />1537
<br />18c. DATE (Mo., Day, Yr.)
<br />June 15, 2021
<br />Cremation 0 Entombment
<br />❑ Removal' 0 Other (Specify)
<br />16d CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL, HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />11. PART I. Ernst the chain of events- -diseases, Injuries, or complications4hatt directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />iMMEDIAIE CAUSE (Final `:. a) Colon Cancer
<br />disease err condition resulting
<br />onset to death
<br />Months
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequenhaly list conditions, if b)Congestive Heart Failure
<br />any, leading to the cause listed
<br />on line (Inc..
<br />onset to death
<br />Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Severe Calorie Malnutrition
<br />(disease or injury that initiated
<br />onset to death
<br />Months
<br />tit. events remitting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART I1. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE::
<br />0 Not pregnant within past year
<br />❑. Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ oriver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES NO
<br />❑-- Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 49 days to 1 year before death
<br />. unknown if within the past year
<br />❑pregnant
<br />❑ Suicide ❑Could not be determined
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />228. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, ice building, construction site, etc, (Specify)
<br />22d. INJURY AT WORK?
<br />OYES ;❑NO,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.LOCATION IOF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />L'
<br />4
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 8, 2021
<br />to
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />1 P ,
<br />g a 2
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 10, 2021
<br />23c. TIME OF DEATH
<br />03:22 AM
<br />I g 1 Y
<br />O.I ` 4
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />0 40
<br />Bo.
<br />i
<br />t3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to thecause(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />mz i
<br />E
<br />•-ff :s
<br />24e. On me basis of examination and/or Investigation, M death my opinion deaoccurred at
<br />lTRIOo the time, date and place and due to the causerie) stated. (Signature and T
<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 />0 YES ® NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO [i YES ❑ NO'
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE Q Q
<br />r
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 14, 2021
<br />
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