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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY 000. ES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COP(OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA :;DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />;DATE OF ISSUANCE
<br />3/30!2023 .
<br />LINCOLN, NEBRASKA
<br />E
<br />304
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />t DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />John Ronald Mataika
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Rockville, Nebraska
<br />SOCIAL SEavaITY NUMBER
<br />506-443309
<br />8b. FACILITY -NAME Of iftft Institution, give street and number)
<br />30 Chantilly St
<br />8c CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand lslald 88803
<br />9a. RESIDENCE-sTATE
<br />Nebraska
<br />9d BTRSETAND NUMEER::
<br />30:`Chantllldr' St
<br />Bb. COUNTY
<br />Hall
<br />lea, MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />19. FA7:IER'S-NAME (First,. Middle, Last, Suffix)
<br />!~rank Mateika
<br />13. EVERVN U S.. RMED FORCES? Give dates of service ifYes.
<br />(Yes, No, or Unk.) Yes 10/29/1956-08/05/1960
<br />16. METHOD OF DISPOSITION
<br />❑ ;auiteli ..;.❑ Donason
<br />® ;Cremation I❑ Entombment
<br />❑ Removai ❑ Other (Specify)
<br />511. AGE - Last Birthday OD. UNDER 1 YEAR
<br />(Yrs.)
<br />85
<br />MOS.
<br />DAYS
<br />Se. PLACE OF DEATH
<br />HOSPITAL C: Inpatient
<br />0 ER/Ou patient
<br />DQA.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />Be. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />23 03900
<br />3. DATE OF DEATH (Mkt, pay,
<br />March 22, 2023
<br />8. DATE OF BIRTH 1910., Day, 4'r.)
<br />June 17, 1937
<br />OTHER 0 Nursing HomeiLTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />91. ZIP CODE
<br />68803
<br />Hospice FaclKty
<br />9g. IN8.DE CITY LIMITS
<br />YES 0 NO
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Donna Hawley
<br />•12 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Cla1a Niaberk
<br />14a. INFORMANT -Meta
<br />Donna Meteika
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State),
<br />AO Faiths Funeral Home, 2929 S. Locust Street, Grand Island Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH Mee €nstructiOne add examples)
<br />1$. PART I. Enter the chain of events- 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 />IMMEDIATE CAUSE:
<br />tMMemaiecAu Pinot a) recurrent adenocarcinoma of colon with peritoneal, hepatic and pulmonary metastasis
<br />d1s0000 orcendittert reaulbng
<br />In dem DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially list conditions, R b) adenocarcinoma of colon
<br />any, leading to the: Cause gated
<br />on arie' a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enterthe INDERL"IING CAUSE C)
<br />idisearitor injuryythat initiated
<br />the events resulting in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />14b. RELATIONSHIP TO DECEDENT:;.:
<br />Spouse
<br />18c. DATE (Mo., Day, Yr.)
<br />March 23, 2023
<br />'S'T'ATE
<br />Nebraska
<br />171. ZiB,Code
<br />588c11
<br />APPROXIMATE INTERVAL
<br />onset to deet8:
<br />Years
<br />onset to death
<br />Years
<br />18 PARTit OTHER SR3Ntt CANT CONDITIONS -Conditions contributing to the death but not resulting in. the underlying cause given In PART I.
<br />Coronary ItrtSfy dise555, hypothyroidism, nephrolithiasis, benign prostatic hyperplasia, COVID 19
<br />pregvdt
<br />namhin past year
<br />tot:.
<br />p Ptegnantatt ate Of death
<br />f , Notpregnent, but pmgnahi within 42 days of death
<br />Not pregnant, but pregnant 43 days tot year before death
<br />Unknown if pregnant withinthe pest year
<br />DATE OF 1t RY (Mtt.,'Cay, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES .❑NO;,;,_
<br />21e. MANNER OF DEATH
<br />Natural .. ❑ NoroitIde
<br />❑ Accident ❑ Patiditjg Inveetigetldn
<br />❑ Suicide ❑Could not be datarninad
<br />22b. TIME OF INJURY
<br />22c. PLACE OP INJURY:::t
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CAT ON'OF INJURY =STREET & NUMBER, APT.NO. CITY/TOWN
<br />0.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 22, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 22.::2023
<br />ImTotlse be0t M my knowledge, death occurred at the time, date and place
<br />and rue td Otte hause(s) stated. (Signature and Title)
<br />Jay C. Anderson, MD
<br />23c. TIME OF DEATH
<br />12:18 PM
<br />21b, IF TRANSPORTATION INJURY
<br />DriverlOperetor
<br />LI Pasaeager
<br />Pedestrian
<br />0 Other (Specify)
<br />19. WAS MED(CALEXAMtNER
<br />OR CORONERCONTACTEO?
<br />❑ YES ®NO'
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El
<br />'IIID
<br />21d. WERE AUTOPSY FiNDING8 AVA)LABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑„ NO
<br />home farm, street factory, office building, construction site, stc (Spacityl
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the bads of examination and/or investigation, in my opinion death ssirredei
<br />tits titre, date and place and due to the causes) stated. (Bignsaae aad ides) •
<br />?5. Dip TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />(I YES Q NO `PROBABLY 0 UNKNOWN
<br />17. NAME, rri.l AN0AD ESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island Nebraska, 68803
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />28a. REGISTRAR'S SIGNATURE )
<br /><- lit- 2a JAI ,d.1t'?4
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26e is NO ❑ Yes 't,j NO::.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day Yr.) I
<br />March 27, 2023
<br />
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