|
.,,
<br />I it I (
<br />1 a, ... I d 3
<br />sI r`" I n
<br />((�� ti `� �y �yyg 1, l yg g ��V3lldl..ll.(dd,6%IPtaautatt.l,Vl(S.)d�,f.ear�it3�atldd1111 ll,Ie�'tu..e,,�a<.IddAVr,tRi2 r ' $4
<br />V('i((liJ1Ai1 ����r r�y83�s�aia4ttr�V���''ICikl'Iti'lsat�0 �V� lllid4��k2i3t'cVAb��7�IdidrrI,idiRrtitax IIAJda>`3�
<br />Sqtea3 :'( STATE OF NEBRASKA i I ;E
<br />�1',,tppPA a MIr7uGAlis tbbit)t t'/#0/((�I{ gQd$Ai 37utYid.nt •:,V,6A AAA33* K,xr. Axa 4,TAA' AAAws..x e48atttNDAtt
<br />:+�':eo.-.••�� ,.rw.•§..ez_.,....gists'viiea.:..A4ii�GiA1..:<x.rrc,...-.:-...:..'�vs,:- fA'iAl'�A �:z.5o.;.,._.,..:._..�..s`a<.i.-e..-.
<br />700(thh1
<br />A
<br />Ih'
<br />��S��ahlatlt4Y�)jj�
<br />" fit Ott#$
<br />$�I��a`A
<br />ter y it(itoni %)1
<br />htYr,�iY4- s6lr
<br />SAI. V1 a'� _ 1y1
<br />Irli)r
<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 />9/22/2016
<br />LINCOLN, NEBRASKA
<br />202106983
<br />are
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF'HEAI_THIAND HUMAN SERVICES
<br />CERTIFICATE OF DEATH'
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jack Eugene Zlomke
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />89
<br />lib. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS. DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 12, 2016
<br />6. DATE OF BIRTH (Mo.Day, Yr.)
<br />November 27, 1
<br />926`
<br />7. SOCIAL SECURITY NUMBER
<br />506.-20-5370 ..
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />© ER/Outpatient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />❑ Hospice Facility
<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 />9d. STREET AND ainieeR
<br />233 East 19th Street
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS"
<br />E YES ❑ NO
<br />105. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (Fest, Middle, Last, Suffix)
<br />Ludwig A Zlomke
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) B wife, give maiden name
<br />Virginia Lee Archer
<br />1 12. MOTHER'S -NAME (First, Middle,
<br />Hazel E Watson
<br />Maiden Surname)
<br />43. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, NO, or Unk.) Yes 03/28/1945-12/09/1946
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />O Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME.
<br />Virginia Lee Zlomke
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />18c. DATE (Mo., Day;' Yr.)
<br />September 14, 2016
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />CITY I TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17b. tip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />IS PAR 1. Ater gwe:4haln of events --diseases, injuries, or complications -that directly caused the death. DO NOT enter **nonfat events such as cardiac arrest,
<br />respiratoryarrett, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Iine. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Exacerbation Congestive Heart Failure
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />aequentlally tiet conditions, if
<br />any, Leading tothe Cause gated
<br />on lines. ..
<br />Enter the UNDERLYING CAUSE
<br />tdiseaea OrinlurY trill 1°0044
<br />the events resulting in death)
<br />LAST s:
<br />APPROXIMATE INTERVAL.
<br />onset to death
<br />3-4 Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Arteriosclerotic Cardiovascular Disease <'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<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
<br />0 Not pregnantwHhln past year
<br />0 Pregnant at time of death
<br />❑ kot ptegnam,.put pregnant within 42 Gays of death
<br />❑ Nit pregnant, but pregnant W days to 1 year before death
<br />❑ titiknawn 1*pregnatt Within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />21a. MANNER OF DEATH
<br />Na I 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />DriverlOperator
<br />0 Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />onset to death
<br />onset
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />1 YES 0 ND
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSEOF (MATH/>
<br />❑ YES ❑ NO
<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 />September 12. 2016
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 15 2016
<br />23c. TIME OF DEATH
<br />11:13 PM
<br />tad. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the unreels) sated. (Signature and Thi,)
<br />Richard Fruehling, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />EI YES 0 NO • 0 PROBABLY 0 UNKNOWN
<br />a
<br />S
<br />1Yo
<br />Cg
<br />el 3
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />21P CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the outsets) stated. (Signature and Tine)
<br />26a. HAS ORGAN OR TISSUE ®• TION BEEN CONSIDERED?
<br />❑ YES III NO
<br />26b. WAS CONSENT GRANTFLAA't
<br />Not Applicable if 28a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand I -Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR
<br />September 16, 2016
<br />Mo, Day, Yr.)
<br />1
<br />
|