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<br />U�__ .,_ STATE OF NEBRASKA
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<br />WKEN:7'HIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA : DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />el
<br />0
<br />DArr:oF tss(I4NCE
<br />......... ...........
<br />.. .........................
<br />LINCOLN, NEBRASKA
<br />2025 04 51 3 04JI
<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 />(.DSCECIgrl Amir>(Fire4, Middle, Last, Suffix)
<br />Anton i;itfTles . Kvvtensky
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday:::
<br />(Yrs.)
<br />CIAL segyalTY:NUMBER
<br />508 40=4777
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Arbor,Care. Centers -Fullerton LLC
<br />Se.:CITY'OR..TOWN.OFDLA;TH (Include Zip Code)
<br />FUUerton :68638
<br />9a. NESIDENCeBTAtE
<br />Nebraska
<br />ed. STREET AND NUMBER:;.
<br />2115 N Sherman Blvd
<br />9b. COUNTY
<br />Hall
<br />104; MARITALSTATUS;IIT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />84
<br />Sb..UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5e. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE CIF DEATH
<br />HOSPITAL Q Inpatient
<br />0 ER/Ou patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />22 02088
<br />3. DATE OF DEAD (Mica .O ' Y 4
<br />February 2. 2022
<br />6. DATE OF 1RTMI`01o„ Day; :Yr:)
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d, COUNTY OF DEATH
<br />Nance
<br />BC(11100.917Y IrIM I r'
<br />YES :O O
<br />lob. NAME OF SPOLj.SE (First, Middle, Last, Suffix) If wife, give maiden namerterntit,
<br />Mary Elizabeth Morrow
<br />Be. APT. NO.
<br />11. FATHER'S NAM( 1Prst,, Middle, Last, Suffix) 1 12. M STHER'BNAME (First,
<br />LadiStav :: Kvetenskv
<br />13. EVER IN U 3 ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 08/31/1961-08/30/1963
<br />18. METHOD OF DISPOSITION
<br />Burial ❑Dgnatlon
<br />❑Cremation ❑i+ntortrsinent
<br />❑ Removal, ❑ Ottier (Specify)
<br />. Martha Janicek
<br />14a. INFORMANT -NAME
<br />Mary Elizabeth Kvetenskv
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />11a. FUNERAL::HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Fa Ms Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />..16b. LICENSE NO.
<br />1071
<br />9f. ZIP CODE
<br />68803
<br />Middle, Maiden Surname
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See: instructions and examples)
<br />8. PART I. Enter the chain of events- dissasas, injuries, or complications4het 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 />�Mt p1ATELtatt9EtFlnat € a)Acute Congestive Heart Failure
<br />diteflge gl*EildttiO0 reeldlinM
<br />in death):: ...... .....
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />Any, )eedtng to the;.cauee;heted
<br />DUE TO, QR AS A CONSEQUENCE OF:
<br />Entfrthe tt NOERt.YtNG ALYSE' C)
<br />(diststaker injury that initiated
<br />the events resulting in death)
<br />UST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 ::PART It,.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death
<br />CardiorliyopathyDiabetes
<br />20. IF FEMALE: .
<br />Not Rregnant Within pest eer
<br />pregnant at•:Nms bf death::::..
<br />•
<br />0
<br />Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑..Unklfown if prsgnaflt wtihin the past year.
<br />2a ;DATE OFThUIJRY (Mo. Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES
<br />2F UOCATI.ON>0F 1
<br />23a. DATE OF`DEATH (Mo., Day, Yr.)
<br />r ce February 2, 2022
<br />not resulting in the
<br />21a. MANNER OF DEATH
<br />® Natural ❑;:.Norticide
<br />0 Accident 0 Pending invpngaddn
<br />❑ Suicide
<br />22b. TIME OF INJURY
<br />derlying cause given in PART 1.
<br />21b,.IF TRANSPORTATION INJURY
<br />EtiOnver/Operator
<br />EtPascringer
<br />0 Pedestrian
<br />0 Other (Specify)
<br />14b. RELATIONSHUPQDECEt9E
<br />Spouse ..
<br />16e. DATE (rito.,`t
<br />February 11 .2022
<br />Zip: C
<br />68801
<br />APPROXIMATEINTER1tA
<br />14.
<br />one
<br />ail
<br />fa. WAS MEDICAL:EXAMlNr
<br />OR CORONER DONTAC: 'ED'
<br />El Yes ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ia.ND
<br />❑Could not be determined 21d. WERE AUTOPSY F)NEtNGS AVAN ABLE,
<br />TO COMPLETE CAUSE. OF DEATH?
<br />❑YES [ENO
<br />22c. PLAC OF INJURY At home, farm, street, factory, office building, construction site etc ($I
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STREET & NUMBER, APT.NO.
<br />23b. DATE SiGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Febryary 3,>2022 09:00 PM
<br />28d To the best of my;knowledge, death occurred at the time, date and place
<br />atitl use(e) stated. (Signature and Title)
<br />Bridgette L Pudwill, MD
<br />2.6. DID:,.TQBACC O USE CONTRIBUTE TO THE DEATH?
<br />XI YES j NO ❑ PROBABLY 0 UNKNOWN
<br />27 :NAME, TITLE ANDApDRESS OF CERTIFIER (Type or Print
<br />8ridgette't: PudvulH, MD, 1019 S 8th St, PO Box 350, Albion, Nebratka,68620
<br />28a. REGISTRAR'S SIGNATURE
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEA
<br />24d. TIME PRONOUNCED DEAD
<br />4e. On1he basis of examination and/or Investigation, in my *pin
<br />the dine; date and place and due to the causes) stated. (Sign
<br />26a. HAS ORGAN OR TIssup DON.ATION BEEN CONSIDERED?
<br />DYES li a .,
<br />and YIi
<br />26b. WAS CONSENT GRANT€D?..:..;...
<br />Not Applicable If 26a Is NO yes
<br />28b. DATE FILED BY REGISTRAIT (Mo.,jDay, Yr.)
<br />February 13, 2022
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