|
((194'9iiiiniiikFl4raa0111141111 t iatiiii01t(Is6eviatillillI tti111I1g;;;i1(iiliiiATiili((i9j',i;; MONA, ihIl„xlvoe, iii: ilQ,etii¢iiLnlJ
<br />uaff/9l>tattanatt r3Y_STATE OF NEBRASKA
<br />c At/YAVnr• t¢tattt►(Jlfaaatrx ... r ir4eMPAtJYtr z
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE E NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />Da 1'E: oF,ssoitggE
<br />2/9/2023
<br />LINCOLN,'NEBRASV
<br />202301206
<br />304
<br />SARAH BOHNENKAMP"j
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CEDENT'S NAME (First, Middle, Last, Suffix)
<br />i(zabettt Ann ..I3rudik
<br />CERTIFICATE OF DEATH
<br />4. CtTY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Columbus, Nebraska
<br />T sttclALSEDi1R1TYNUMBER
<br />5a. AGE - LaSt Birthday
<br />(Yrs.)
<br />79
<br />Sb.'FACILITY-NAME (If not Institution, give street and number)
<br />4235.Auousta Pkwy
<br />Sc CITY OR TOWN OF DFATH (Include Zip Code)
<br />Geand Isla;rid $8803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER::
<br />4235 Augusta Pkwy
<br />9b. COUNTY
<br />Hall
<br />1oa A1ARITAL STATUS AT' TIME OF DEATH ® Married 0 Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME. (First; Middle, Last, Suffix)
<br />'Ward E Jedlicka
<br />13. EVER IN U S ARMED Ft ROES? Give dates of service if Yes.
<br />(?fag No, or Unk) No.: ';
<br />15. METHOD O,F DISPOSITION
<br />❑'burial QDona€on
<br />Cremation ❑ Entombment
<br />❑Removal ❑Other,(Specify)
<br />5b'UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a.PLAGE OF DFJATH
<br />NOSPtTAw ❑ NtpaNarit
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH. (Mo ,Thiyi
<br />Januar 2, 2023
<br />6. DATE OF BIRTH (Ma,
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />e•
<br />Facility
<br />1Ot. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife,
<br />Thomas Jerome Drudik
<br />fdenname
<br />12, MOTHER'S=f±NAME (First, Middle, Maiden Surname)
<br />AQnuS Mares
<br />14a. INFORMANT -NAME
<br />Thomas Jerome Drudik
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a, PUNERAL:MOMS NAME AND MAILING ADDRESS (Street, City or Town, $tate)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island.: Nebraska ;.
<br />16b. LICENSE NO.
<br />CAUSE OF DEATH (See instru
<br />CITY / TOWN
<br />Gibbon
<br />ci YUMti$"
<br />14b. RELATIONEH1PTO DECEDENT'
<br />Spouse
<br />16c. DATE (Mo., Day, Xe )i
<br />January k2023
<br />onsond examples)
<br />18. PART I. Enter the chain of events- 41seases, Injuries, or complicaaonsthat directly caused the death. DO NOT enter terminal events such es 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 />IMMEDIATE CAUSE:
<br />a) Pancreatic Cancer
<br />IMMEDIATE CAUsE (Final
<br />disemse or0dndffun re40Etr
<br />in dead
<br />Sequentially Est conditions, it
<br />any,.leading to the caues Rated
<br />Enter the UNDERLYING: CAt78L.
<br />(disease or Injurythetintttatd
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, ORAS ACONSEQUENCE OF:
<br />d)
<br />18. PART it OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting
<br />Chronic Obstructive Pulmonary Disease, hypertension, diabetes
<br />20. IFI.FEMALE;::;;
<br />Mot pragnatt Ydtltin l yeAr
<br />[ j Negitam 411Me of 0eatly
<br />Not pregnast but pregnant w@hhl 42 days of death
<br />'pregnant, but pregnant 43 days to 1.. year befors death
<br />Unknown It.piegnaatv'ritldn the past year
<br />22a,DATEOF1140RY(Mv:Day,Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES :❑ NO:'.:.
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Imresdgatlon
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b.
<br />STATE
<br />Nebraska
<br />1?b. rt{p:G
<br />8880"1;.:
<br />APPROXIMATE INTERVAL
<br />onsetlOdepltlt:
<br />Month!
<br />he underlying cause given In PART I.
<br />F TRANSPORTATION INJURY
<br />Ddvedoperator
<br />QPassenger
<br />Pedestrian
<br />❑ Other (Specify)
<br />onset to death
<br />19. WAS MED f,"rA .EXAMINER
<br />OR CORONER BONTACtED''
<br />O YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />d YES ®NO
<br />21d. WERE AUTOPSY RNDINGS AiiAHABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, constmt:ttlon site, etc':(SI
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY; -STREET & NUMBER: APT.NO.
<br />33a. DATE OF DEATH (Mo., Day, Yr.)
<br />E' January 2, 2023
<br />CITvl'o N:'
<br />23b DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />January 4 :2023 04:45 PM
<br />23d 7a the berm of my knowledge, death occurred at the time, date and place
<br />and due to the causels) stated. (Signature and Thee)
<br />Chad Vieth, MD
<br />f4 r,
<br />r
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e PRONOUNCED DEAD (Mo., Day, Yr.)
<br />P;�
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the lusts of examination and/or investigation, Miry opinion death en.turod at
<br />the lime; elate and place and due to the ause)s) stated. (Signature std) de).
<br />26a. HAS ORGAN;OR TISSUE DONATION BEEN CONSIDERED?
<br />�I ❑ YES J NO
<br />s17 ,NAME�'Efii tN ApifRESS OF CERTIFIER (Type or Print
<br />Grad Vieti , M13.1116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />25. DiD TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES NO PROBABLY 0 UNKNOWN
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO D IES
<br />ONO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr)
<br />January 13, 2023
<br />
|