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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE CO'PiOP 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 />3/3Oi2O23
<br />LINCOLN, NEBRASKA
<br />1 DECEDENTS -NAME (First, Middle
<br />John Rcirlald Matejka
<br />202301957
<br />30-4
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
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<br />STATE OF NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Suffix),
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR: TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Rockville, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-44»3309
<br />Ba. AGE Last Birthday
<br />(Yrs )
<br />85
<br />8b. FACILITY -NAME (Snot Institution, give street and number)
<br />30 Chantilly St
<br />Sc Crty OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803'
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d S.TREETAN)'NUMBER;::
<br />3D Chan .Wy>St
<br />9b. COUNTY
<br />Hall
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑-I ERIOu patient
<br />D DOA.
<br />10a, MARITAL S'CATUS AT TIME'OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11 0:41RIER S NAME ( 's%
<br />Frank Matelka
<br />Middle,
<br />Last,
<br />Suffix)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Link.) Yes 10/29/1956-08/05/1960
<br />15. METHOD OF DISPOSITION
<br />❑'Burial 0 Dona(gn
<br />cremation',❑Entombment
<br />❑ Removal '0 other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo , Dayr Yr );;::,
<br />March 22, 2023
<br />6. DATE OF BIRTH (filo., Day, Yr.)
<br />June 17, 1937
<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 />Hdspice FachiHy ;,'.
<br />900NSWpe CITE UMITB:',';
<br />� mEs D No`
<br />10b NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Donna Hawley
<br />12. MOTHER'S NAME (First, Middle,
<br />Gate Niaberk
<br />14a. INFORMANT -NAME"
<br />Donna Meteika
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />A€l Faiths Funreral Home, 2929 S. Locust Street, Grand Island, Nebraska:
<br />CAUSE OF DEATH (See instructions' and examples)
<br />Maiden Surname)
<br />1E. 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 />IMMEPIATECAu6EM Pini a) recurrent adenocarcinoma of colon withperioneal, hepatic and:: pulmonary metastasis
<br />disease or ¢endnlaiitecanln9'
<br />in death):.;;:: .....
<br />Sequentially list conditions, if
<br />anyr leading toth.causa Bead:
<br />on SI1R a
<br />Enterte VNABRL:`.
<br />(disease err inlaytn
<br />the events resulting in death)
<br />LAST
<br />YiNG 'CAWB#
<br />et initiated
<br />DUE TO, OR A CONSEQUENCE OF:
<br />b)adenocarcinoma of colon
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C).
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />18e. DATE (Mo Day, Yr.)
<br />March 23202;
<br />STATE
<br />Nebraska
<br />13b. Zip;Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Years
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />18. PART h. OTHER SIGNIFICANT CONDITIONS-Condhions contributing to the death but not resulting in: the underlying cause given In PART I.
<br />wrongly artery disease, hypothyroidism, nephrolithiasis, benign prostatic hyperptaaia, COVID-19
<br />20. IF FEMALE:;,.:
<br />Mot pregnant within poet year
<br />❑ 0Cegnard at tGthe of 1B10
<br />❑. Nor ptegnaaM, but pregnant within 42 days of death
<br />D .Not pregnant,: but pregnant 4E days to 1. year before death
<br />D Unknown ifpreg.t f4lt iri the pmt year
<br />23a, DATE OF INA! {Mia„ Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES .0 NO
<br />21a. MANNER OF. DEATH
<br />® Natural.. ❑ homicide
<br />❑ Accident ❑ Pendfnpinveati9atiea
<br />,..❑ Suicide ❑ Couldnot be determined
<br />22b. TIME OF INJURY
<br />211)..1! TRANSPORTATION INJURY
<br />❑ ORMONOperator
<br />DPassenger
<br />0 Pedestrian.
<br />❑ Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES' ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES to N.
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction site, 401(4P0041:!.:...::::
<br />1
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />22f. L flCATIONt F INJURY«STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 22, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Mulch 22 ;Q23
<br />CITY/TOWN:
<br />23c. TIME OF DEATH
<br />12:18 PM
<br />To hie east cf my anowtedge, death occurred at the time, date and place
<br />aRE ' due to the atuse(s) stated. (Signature and rebs)
<br />Jay C. Anderson, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />Z)P CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. OnCthe basis of examination andlor investiga ion, in my opinion death Occurred at
<br />.. _..,
<br />MBank date and place and due to the cause(s) stated. (Saha-tura aratitte)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES ® NO
<br />a8 DIP:TQBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES NO U PROBABLY' 0 UNKNOWN
<br />727 NAME, TITLE>i. 0 ADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, IVID, 729 North Custer Avenue, Grand Island, Nebraska, 68803'
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable it 28a Is NO O YES :.❑
<br />6)1-4a...A ,,e6.4 -r -p.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 27, 2023
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