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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF k FA%Tti-ANgtRI•414 SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS,KeEP,ARTMe +4?E, >iEAI:,TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY POR'1aTAL,, ECORb51'
<br />DATE OF ISSUANCE
<br />202202336
<br />, STs4 JLEY S.COOPER -. .1 r' '
<br />g ANT STATE REGISTRAR, •
<br />DEPARTMENT OF HEALTH AND.? •
<br />H -SERVICES
<br />MAY 2 2 2009 �r R*
<br />LINCOLN, NEBRASKA
<br />r
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI !'Satre./ �) a
<br />CERTIFICATE OF DEATH s a �.
<br />To Be CompletedNerified by: FUNERAL RECTOR
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Harvey Eugene Zichek
<br />2. SEX • t
<br />Male `-°'t
<br />3 tutteoF gFjATH (Mo:,DayrYl)
<br />"` -
<br />4. CITY 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 />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Lincoln, Nebraska
<br />(Yrs.)
<br />83
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 25, 1925
<br />7. SOCIAL SECURITY NUMBER
<br />507-36-5695
<br />8a. PLACE OF DEATH
<br />HOSPITAL; ® Inpatient OTHER: ❑ Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />0 ER/Outpatlent 0 Decedent's Home
<br />0 DOA 0 Other(Specify)
<br />Saint Francis Medical Center
<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 />3110 N. Webb Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<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 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Debris May
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ed Zichek
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Agnes Varga
<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 />Deloris Zichek
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16. METHOD OF DISPOSITION
<br />El Burial ❑Donation
<br />lea ER -SIGNATURE '
<br />CCt -A t' / -
<br />16b. LICENSE NO.
<br />f 9 7
<br />16c. DATE (Mo., Day, Yr.)
<br />May 18, 2009
<br />0 Cremation ❑Entombment
<br />❑Removal ❑Otherlapecify)
<br />6d. CE ETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Central City Cemetery Central City Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG 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 />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of evocid - diseases, Injuries, or complications- that directly caused the death. DO NOT enter terminal events such as cardiac arrest.
<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 />IMMEDIAT CAUSE:
<br />IMMEDIATE r CAUSE (Finalu/ /
<br />disease or condition resulting a) G(.. Q 0 t,.., r \ , P
<br />V
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />y1
<br />7 rnvyy"t Vl S -
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentiallytintconditions, e b) j (' `� -
<br />any, leadingto the cause listed i•( CtJiO aR- Vim.
<br />onsetpto death
<br />/ `„ ,,;n) �;
<br />(� vV �Y !o
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF:
<br />V
<br />onset to death
<br />Enter the UNDERLYING CAUSE el KtY1Cass Lct ss \inti t.` is
<br />l//`Y,(1t
<br />12.6,,,,,, -z -
<br />(disease or Injury that initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<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 L
<br />1 C �f 1
<br />if "CeMp` {%(Z\ VX-(�j-(O$(: i JU'>
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 0 NO
<br />t
<br />20. IF FE : I221a
<br />[Slot pregnant within past year
<br />NIAANNER OF DEATH
<br />i1al crural 0 Homicide
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES QJiicPE
<br />❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />['Unknown H pregnant within the past year
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES .ergo
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES EKtc
<br />22e. DESCRIBE HOW INJURY OCCURRED -
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />g.a
<br />23a. DATE OF DEATH (Mo., Day, Yr.)Z
<br />May 1 4, 2009
<br />a �z
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />U
<br />I
<br />Eaz
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 18, 2009
<br />23c. TIME OF DEATH
<br />5:14 Pe m
<br />ir
<br />= 0
<br />Q.
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />soo
<br />o
<br />Q
<br />23 e y knowl death occyyywed at the time, date and place
<br />and qua to the c se(s state• d.
<br />�,, ignatu d de)
<br />`CJW0
<br />0 0
<br />ri W 2
<br />HCV
<br />V O
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26. DID TOBACCO )8E C NT IBUTE TO THE DEATH?
<br />❑ YES NO ❑ P OBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR 139NATION ON BEEN CONSIDERED?
<br />❑ YES
<br />26b. WAS CONSENT GRANTED? uA..,/
<br />Not Applicable If 26a is NO 0 YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pent)
<br />Ryan Crouch, DeOe, 800 Alpha St., Grand Island, Nebraska 68803
<br />I
<br />P
<br />28a. REGISTRAR'S SIGNATURE 4'.
<br />.� 6,
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAY 2 0 2009
<br />
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