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WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF TilE 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
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<br />0A11.OP:ISSUANt
<br />4/20(}23
<br />LINCOLN, NEBRASKA
<br />202 04183
<br />EDENT'S NAME :(Ipi3at, Mid
<br />David John ,iellnek
<br />SARAH B
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Suffix)
<br />2. SEX
<br />Male
<br />3. DATE"
<br />4. CITYAND STATE OR :TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />GretnA Island, Nebraska
<br />lxi..8E001tITY WADER
<br />p»77816
<br />PACIUTY-NAME ((f n»t institution, give street and number)
<br />Grand !siert(' Regional Medical Center
<br />6a. ADE . Last Birds
<br />(Yrs.)
<br />83
<br />ty
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />April 7,
<br />6. DA
<br />21
<br />Mo..
<br />Feb n rY 23,1:9.40
<br />8a. PLACE ttF 1>EATr(
<br />HosPtrAL j� t leas OTHER ❑ nursing HomeILTC
<br />El ER/Outpatient 0 Decedent's Home
<br />0 Other (Specify)
<br />0 DOA..
<br />CITY Oft TOWN OFDEATH (include Zip Code)
<br />Grand Islard 68803
<br />Iad. COUNTY OF DEATH
<br />Hall
<br />.
<br />RESIDENCE -STATE"
<br />raska
<br />ANC NOMI
<br />darbler Rd':
<br />»MARITAL SI'A1
<br />0 Married, but e
<br />. COUNTY
<br />Hall
<br />9c. CITY, OR TOWN
<br />Grand Island
<br />es. APT. NO.
<br />AT TIME
<br />acted ❑ Wido
<br />Married 0 Never Married
<br />Divorced 0 Unknown
<br />1. FATHER'SNAME:(7F'tate Middle, Last, Suffix)
<br />orpe Vash3nstti ► Jelinek
<br />tab: NAM OF SPOUSE (
<br />Sharon Hargan'
<br />9f. ZIP CODE
<br />68803
<br />YSIDE'x:ITY irliuifi
<br />t, Middle, Last, Suffix) If wife, gi
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sus
<br />Mildred Burgherr
<br />13. EVER IN U'S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk) Yes 1959-1963
<br />16. METHOD OF DISPOSITION
<br />[peltt7eonn
<br />I Creratti n;Cisotort#ment
<br />❑'Removal i]Othor,(Specify)
<br />14e. INFORMANT -NAME
<br />Sharon Jelinek
<br />16a. EMBALMER -SIGNATURE
<br />Andrew D Purcell
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Iestlawn Memorial Park Crematory
<br />lab. UCENSE NO.
<br />1486
<br />CITY i TOWN
<br />Grand island
<br />14b. RE4A9
<br />Spouse
<br />item TD DEcEoBtT.
<br />ism DATE (Mo
<br />ADrii 14,
<br />A
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />iilriaiton;i4Onderrnann Funeral Home. 601 N. Webb Road, Grand Island.._
<br />ka
<br />CAUSE OF DEA' (See:<1nstru li
<br />PART I. Enterthe chain of eveMw .diseases, Injurya,or comphoatlons.that directlycaused the death. DO NOT'a
<br />rpl'story arraet, or ventdculer fibrfilat on without showing the etiology. DO NOT ABBREVIATE. Enter only one aa�.
<br />IMMEDIATE CAUSE:
<br />(UMWe respiratory failure
<br />or cairdfilon result
<br />Sequentially list conditions, E
<br />any. Mading to eiteles itsted
<br />Etdtr mUNBELININGMmai'
<br />ldlesaee of Ipuryaat IriltiateA
<br />i sin 'etut pies)
<br />final eventssuch as cardiac arrest,
<br />one tine. Add additional lines if necessary.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />the
<br />LASeveT nts resulting in death) DUE TO. OR AS A CONSEQUENCE OF:
<br />d)
<br />18
<br />ARTM.
<br />Sis
<br />R SIGNIFICANT CONDITIONS-Conditlona contributing to the death but not ireauiltng`I tthe underlying cause given In PART I.
<br />YI
<br />sttirxe of
<br />pregnata Sut eregaa
<br />❑ Nor,_pregnant, but pregnant 43 days to 1 year before death
<br />unknown tipseOnrnttaMMla the Paan year
<br />DATE OgBUM #SIO., Oey, Yr.) ,.
<br />21a. MANNER OF DEATH
<br />no Natural HomiCide
<br />o
<br />Accident 0 pend(nginvestigation
<br />❑ Suicide 0 Count not be determined
<br />22b. TIME OF INJURY
<br />21x1,. IF TRANSPORTATION INJUI
<br />DnuarFOparator
<br />Passenger
<br />Iredestdan
<br />❑ Other (Specify)
<br />21C W.
<br />21d. LIEF
<br />TO
<br />0
<br />22c. PLACE OF INiURYAC hods a atm, street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23b. DATE SIGNED (Mo., parr, Yr.
<br />Aoril1t 20.23
<br />Md.'To he best of myrknowledge. desi
<br />**due titI*0 e(a) mated; (8
<br />Jose "Salo, APRN
<br />TE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />occurred at the time, date and place
<br />nature and Title)
<br />tin thelxlsis of examination andfor investigation, In my aP
<br />ilia altarolate end place and due to the seams) stated. tit
<br />28 DID TOBACCO LIME CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES FANO ❑' PROBABLY 0 UNKNOWN I ❑ YES Nlip O
<br />ZT .. E, `#IT(....' D ADDRESS OF CERTIFIER (lyipe of Prin
<br />Josse Bajo,>APRN, 3533 Prairieview St, Grand Island, Nebraska, 68803
<br />28s. REGISTRAR'S SIGNATURE
<br />28b. WAS COat
<br />Not Applicable if
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 17, 2023
<br />
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