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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTME THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPO DATE OF ISSUANCE FEB 0 5 2010 LINCOLN, NEBRASKA .S, IT CERTIFIES TN AND STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCfYU CERTIFICATE OF DEATH 176 FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livin:ston-Sondermann Funeral Home 601 N. Webb Road Grand Island �IS PART I. Enter the dein of event, --diseases, in(urles, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac sweet, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional blies a necessary, )( IMMEDIATE CAUSE: (a) Kr IMMEDIATECAUSE(Fknl dissimilar condition readtIng IodMh) Sequentially fist conditions, ff any, leading to theeause Hated online& Enter the UNDERLYING CAUSE (dieeaMorb* 17ttlatinitialed Bnevai.r aul gtndeal) UST (4Al2,14111AL. otDUE TO, 0R AS A CONSEOUyNC OF: ro) DUE T0, OR AS A CONSEQUENCE OF: (c) 68803 APPROXIMATE INTO WYAL .onset to death Q / r onset to death onset to death DUE T0, OR AS A CONSEQUENCE OF: (d) I onset to dMel 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the deem but not resulting In the underlying cause given in PART I. lift. WAS MEDICAL EXAMINER OR CORONER CONTACTED? O YES ONO )620.1 EMALE: Not pregnant within past year ❑ Pregnant at time of death O Not pregnant, but pregnant within 42 days M death 0 Not pregnant, but pregnant 43 days to 1 year before death ,O Unknown it pregnant within the past year 941a. MMANNER OF DEATH U'fatural ❑Homicide ❑ Accident❑ Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURYf21o. WAS AN AUTOPSY PE . ORMED? 0 Driver/Operator ❑ YES NO ❑ Passenger O Pedestrian O Omer (Specify) ',lad. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF 0 YES PerNO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Spedty) 22d. INJURY AT WORK? ❑ YES ❑ NO - 228. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY . STREET 8 NUMBER, APT. N0. 443a. DATE OF DEATH (Mo., Day, Yr.) January 28, 2010 SIGNED (Mo., Day, Yr.) 29, 2010 24a. DATE SIGNED (Mo.. Day,Yr.) 246. TIME OF DEATH C 23c. TIME OF DEATH 1:05 p m 23d. o the 1180 of my knowledge, death occurred at the time, date and place and due the ctplse(s) nt ; gnature and Title) 1T a- vE 24e. PRONOUNCED DEAD (Mo.. Day,Yr.) 24d. TIME PRONOUNCED DEAD m 24e. On the basis of examination and/or instigation, in my opinion death occurred et the time, date and place end due to 1M auu(s) stated. (Signature and Title ) • CONTRIBUTETOTHE r H? 8 6a. HAS ORGAN OR TISSUE D0 IATION BEEN CONSIDERED? '*28b. WAS CONSENT GRANTED? ❑ YES /� NO 0 PROBABLY 0 UNKNOWN O YES oa NO Not Applicable if 26a is NO 0 YES Q NO NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type orPrin John A Wagoner M.D. 800 Alpha Street Grand Is and NE 68803 28a.. REGISTRARS SIGNATURE 11, A (Ayr, 28b. DATE FILED BY REGISTRAR (Mo., Day. Yr.) FEB 3 2010 HHS -61 11/03 (55061) 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 12. SEX Ethel Belle Rezabek Female - 3: DATE OF DEATH (Mo.,Day, Yr.) Jan. 28. 2010 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 55. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) Paxton, NE (Yrs.) 80 MOS. DAYS HOURS MINS. Feb. 16, 1929 /. SOCIAL SECURITY NUMBER 505-32-7955 8a. PLACE OF DEATH )HOSPITAL: Xllnpatient cm OMurales Horne/LTC 0Hospice Facility Bb. FACILITY -NAME (If not institution, give street and number) 0 ER/Outpetlent 0 Decedent's Honig 0 co% ❑ Other (Specify) St. Francis Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 Sd.COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 911. COUNTY Hall 9e. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 216 South Eddy 9e. APT. NO 91. ZIP CODE 68801 9g. INSIDE CITY LIMITS ZI YES ❑ NO 10a. MARITAL STATUS ATTIME OF DEATH Y) Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First. Middle, Last. Suffix) If wife, give maiden name. Carl Rezabek 11. FATHER'S -NAME (First, Middle, Last, Suffix) Jean E. Mason 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Eunice Woodcock 13. EVER IN U.S. ARMED FORCES? Give dates of service It yes. (Yes, no, orunk.) NO 14a. INFORMANT -NAME Carl A. Rezabek 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION raBurial ❑Donation Dia Cremation 0 Entombment 0 Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE s 18b. LICENSE N0. 1325 1 Sc. DATE (Mo., Day, Yr. ) Feb. 2, 2010 16d. CEMETERY, CREMATORY OR HER LOCATION CITY / TOWN STATE Westlawn Memorial Crelmatezy Grand Island NE. 176 FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livin:ston-Sondermann Funeral Home 601 N. Webb Road Grand Island �IS PART I. Enter the dein of event, --diseases, in(urles, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac sweet, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional blies a necessary, )( IMMEDIATE CAUSE: (a) Kr IMMEDIATECAUSE(Fknl dissimilar condition readtIng IodMh) Sequentially fist conditions, ff any, leading to theeause Hated online& Enter the UNDERLYING CAUSE (dieeaMorb* 17ttlatinitialed Bnevai.r aul gtndeal) UST (4Al2,14111AL. otDUE TO, 0R AS A CONSEOUyNC OF: ro) DUE T0, OR AS A CONSEQUENCE OF: (c) 68803 APPROXIMATE INTO WYAL .onset to death Q / r onset to death onset to death DUE T0, OR AS A CONSEQUENCE OF: (d) I onset to dMel 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the deem but not resulting In the underlying cause given in PART I. lift. WAS MEDICAL EXAMINER OR CORONER CONTACTED? O YES ONO )620.1 EMALE: Not pregnant within past year ❑ Pregnant at time of death O Not pregnant, but pregnant within 42 days M death 0 Not pregnant, but pregnant 43 days to 1 year before death ,O Unknown it pregnant within the past year 941a. MMANNER OF DEATH U'fatural ❑Homicide ❑ Accident❑ Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURYf21o. WAS AN AUTOPSY PE . ORMED? 0 Driver/Operator ❑ YES NO ❑ Passenger O Pedestrian O Omer (Specify) ',lad. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF 0 YES PerNO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Spedty) 22d. INJURY AT WORK? ❑ YES ❑ NO - 228. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY . STREET 8 NUMBER, APT. N0. 443a. DATE OF DEATH (Mo., Day, Yr.) January 28, 2010 SIGNED (Mo., Day, Yr.) 29, 2010 24a. DATE SIGNED (Mo.. Day,Yr.) 246. TIME OF DEATH C 23c. TIME OF DEATH 1:05 p m 23d. o the 1180 of my knowledge, death occurred at the time, date and place and due the ctplse(s) nt ; gnature and Title) 1T a- vE 24e. PRONOUNCED DEAD (Mo.. Day,Yr.) 24d. TIME PRONOUNCED DEAD m 24e. On the basis of examination and/or instigation, in my opinion death occurred et the time, date and place end due to 1M auu(s) stated. (Signature and Title ) • CONTRIBUTETOTHE r H? 8 6a. HAS ORGAN OR TISSUE D0 IATION BEEN CONSIDERED? '*28b. WAS CONSENT GRANTED? ❑ YES /� NO 0 PROBABLY 0 UNKNOWN O YES oa NO Not Applicable if 26a is NO 0 YES Q NO NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type orPrin John A Wagoner M.D. 800 Alpha Street Grand Is and NE 68803 28a.. REGISTRARS SIGNATURE 11, A (Ayr, 28b. DATE FILED BY REGISTRAR (Mo., Day. Yr.) FEB 3 2010 HHS -61 11/03 (55061)