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ST Tt OF tflIMASKA.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASIDEPARTMENT
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOS
<br />DATE OF ISSUANCE
<br />69
<br />04/29/2015
<br />CI 23.
<br />`
<br />LINCOLN, NEBRASKA ' r
<br />STATE QF NEBRASKA - DEPARTMENT OF HEALTH AND
<br />CERTIFICATE OF DEATH
<br />S
<br />4
<br />wy,I.
<br />w9d.
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<br />1. DECEDENTS NAME (First, Middle, Last, Suffix) a
<br />Arlene Marjorie Zessin f
<br />2:Ig ; + ,
<br />1 .,
<br />�- TEVElw, ow,yt.)
<br />r , „ , .2015 '•
<br />. Cr'eY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OP BIRTH
<br />tit. AGE • Last Birthday
<br />lb UNDER 1 YEAR
<br />Be, UYNDER 1 Yi ,,
<br />-e AIhOP•6StTit tMo:, Day Yr.)
<br />Magnet, Nebraska
<br />(Yrs-)
<br />78
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS..
<br />'
<br />-
<br />:` January 13, 1937 .
<br />7. SOCIAL SECURITY NUMBER
<br />506-44-2520
<br />ea. PLACE OF DEATH
<br />HO 1TAL 0 Q Q Numb* IioIM.TC:. ::. E) Heipke Fes t
<br />.,.. FACILITY -NAME (t not Institution. give street and number)
<br />,- "'M CHI Health StFrancis
<br />:.:
<br />❑ EIMOut ahent . 0 Decedent's Media ...
<br />JIT9tpfy
<br />. CITY OR TDWNOF DEATH (Inchrde Zip Code)
<br />Grand Island 68803
<br />ett•ddUNTY OF nom
<br />Haft
<br />_ . RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWM
<br />Grand Island
<br />STREET AND NUMBER
<br />916 E 6th Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />eg INSIDE CITY 41M11t8
<br />{ Iasi .
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married El Never Married
<br />0 Married, but separated 0 Widowed E1 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, 'diddle, Last, Stix) If wife, givernelEMwuits -
<br />Harold Victor Zessin
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Walter Wiliam Stuedtrath
<br />12. MOTHER'S -NAME (Find, Middle, Maiden Effitilffild •
<br />Hattie Clapp .
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yea No, or Unk.) No
<br />14s. INFORMANT -NAME
<br />Harold Victor Zessin
<br />14b. RELATIONSHIP -TO DBOEBE T -
<br />Husband
<br />18. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />lab. LICENSE NO.
<br />1454
<br />16s. DATE (Mo., D,ay, Yr.)
<br />April 17,, 2015
<br />0 Cremation 0 Entombment
<br />O Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY r TOWN STATE
<br />Grand Island City Cemetery Grand island Nebraska
<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 />it pOoda
<br />.
<br />CA1SE OF DEAT'H)See l istructiohi3 Ind exirnples)
<br />j�
<br />.
<br />LE
<br />Fcp
<br />N
<br />III
<br />VAccident
<br />LL
<br />.8
<br />IO
<br />le. PART I. anmsrthe fast et egse
<br />alrlitees, 'Nudes, or commieaxssammaxectV saassd the daDOsh. NOT enter tombs, a suet es amities sweet, - ktNNIK XIMAVO ip4f l AL
<br />respirator), award, or veatriaular fIbAaation withal showing the edsls6y. DO NOT AMRINIATE. Elam only one cause en a Ws. Add additional (Moe U xsasary.
<br />IMMEDIATE CAUSE
<br />IMMEDIATE CAUSEtPMat *End-stage Parkinson's Disease •--- -
<br />- disease or condition meultMq .... - -
<br />± Oeste death
<br />. %tile . • •r
<br />- - i _
<br />M death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b)
<br />any, looting to the esus. Hated
<br />ohaeeii iir)a h :
<br />..
<br />°" gas • Due TO, OR As A CONSFAUENCE OF: 'i oh®tit1D dot
<br />Enter the UNDERLYING CAUSE c) t . ..-.. .:..._ ..
<br />(disease or Injury that initiated
<br />i i
<br />die suet* resulting in death) DUE TO, OR ASA CONSEQUENCE OF: t onsetbissealA
<br />LAST d) t
<br />18. PART E. OTHER SIGNIFICANT CONDmONS-Condrnons contributing to the death but not resetting ill the underlying css.e given In PART I.
<br />Recurrent Pneumonia, Aspiration Event, DeDalarativ®Arthritis, Progressive Dementia
<br />19: VIA4SM7; gW ME ,
<br />ORCOIgQNPiGOifYftOTtfitP
<br />Q h
<br />," F FEMALE:
<br />-.❑ Not pregnant within past year
<br />0 Pregnant at Erne of deathPassenger
<br />21a. MANNER OF DEATH
<br />® Natural ❑ NomlUde
<br />Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />/Operr
<br />• DAvs�
<br />0
<br />21c:. WAB AN AUT .
<br />'INV _
<br />.... ..-., .. i
<br />© Not pregnant, but pregnant within 42 dery of daadr
<br />0 Not proq„arA, but pregnant 43 days e 1 year before death
<br />0 Unknown M pregnant within the put year0
<br />❑ Suicide ❑Could not be determined
<br />0 Pedesatsn ,
<br />0 Other (Specify)
<br />21d. V5RE AtITO*tt*.! I�Siea�,a'�'rAMI.*eb
<br />TO cosy alt CMISE F OEATH9
<br />YES 0 '
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TiME OF INJURY
<br />22c. PLACE OF INJURY -At home, faint, street, factory, office building, construction site, Ow (Spssiry)
<br />22d. INJURY AT WORK?
<br />❑ YES ■ NO
<br />229. DESCRIBE HOW INJURY OCCURRED
<br />.
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CRYITOWN STATE EP CODE
<br />26a. OM*, DEATH (Mo., Day, Yr.)
<br />S April 14, 2015
<br />B
<br />94a. DATE il5NEDISEa esyr`lr4 ,
<br />. _ /1ME OF $A* ' N '
<br />;
<br />Pr
<br />Z�
<br />23b. DATESIGNED (Mo., Day, Yr.)
<br />Te.re
<br />2$c.11ME OF DEATH
<br />AM
<br />a'
<br />24c. PRONOUNCED DEAD (910., Day, Yr.
<br />au.Y PIr9 0YI gDI►D
<br />.E
<br />O , :im12;22
<br />e beast of Ery RnovAedge, dead, occurred at the e, date and place -
<br />the best
<br />8 !E and due to the cewe(s) steed (Slgnatw u and 11110m
<br />Jane A. McDonald, MD
<br />,
<br />t..b
<br />24e. Dae* bass alma -Windom Molterl eesdgatlon, M my opinl4n
<br />Me One, date and plass end duo tote cowl$) Mated, (Blgnature aMAAgs) ' '.... . .
<br />29. DI . TOBACCO USE bNTRIBUTE TO THE DEATH?
<br />YES NO 0 PROBABLY 0 UNKNOWN
<br />26e. HAS ORGAN OR
<br />0 YES
<br />?I DONATION BEEN: CONSIDERED?"
<br />®No
<br />26b WAR CONSENT iniNTEO?
<br />Not AppIIsable If2608140YMB ` ({J NQ
<br />,. ME, TITL AND ADDRESS OF CERTIFIER (Type orPdrk
<br />E
<br />Jane A. McDonald, MD, 800 N Alpha Street, Grand
<br />Island, Nebraska, 68803 . ,
<br />REGISTRAR'S AiGNATUNiE /A -
<br />�j
<br />28b DATE FILED BY'REGIS R NMP .tri 1rX
<br />April 20, 20 j
<br />
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