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�._...__.._.-._...... STATE OF NEBRASKA_.__.
<br />°�<24[ri4Wdddgsv»^ .za..td vD =. <+gcenrrrrrrt;ar+.,zatg Fs avttrnnmSvsS
<br />. 44449�Yr.%4445. � . - 44�.7Aid�444N `
<br />tf'TH S, COPYCA ilr5 THE RAISED SEAL OF STATE OF NEBRA.SKA,.:,IT CERTIFIES THE DOCUMENT BELOW TT
<br />• BE:; R'TRCO ; F THE° ORIGINAL RECORD ON FILE WITH THE:NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICrES, 'VITAL'RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE Lkk1F I OA:4CE
<br />r5i2`
<br />LINCOLN, NEBRASKA.
<br />VS-NAMEA irahC Middle, Last, Suffix)
<br />►a€€> AtE;n Rtizicka
<br />202600273 ..ASS STANT STATE REG S'
<br />DEPARTMENT OF HEALTH
<br />f . AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH /
<br />4 CITY AND'STATE OR TERRITORY, OR FOREIGN COUNTRY OFBIRTH
<br />Central City ;>: Nel raaka
<br />T, II 3GIAL S I iTY HUMI EA;.
<br />50 46-1221:::
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />82� :.
<br />b. FACILITY -NAME no
<br />ITT OR TT OF;D TI
<br />rand lstaritt'688Q',
<br />ENCE-STATE
<br />Nebraska
<br />• street and number)
<br />it Zip Code)
<br />Sb.000NTY
<br />Hall
<br />STI EET 10$
<br /><1.00.W.W>1:4th $t
<br />10a: MARITAL STATUS ATTlINE04t3iEATH Married ❑ Never Married
<br />Married, but separated ° Widowed ❑ Divorced ❑ Unknown
<br />tt>FATh NAfIIR ( e( >: Middle,
<br />Lot Ruzidka'';:a
<br />1' .,,EVER Ikl U.s.' ARh E0"FORCES?
<br />(Yes, NO, or Unit.) YES
<br />i / I
<br />Th.: OF DISP::OSfl ON..
<br />ie nano ntombr lt. '
<br />•moval ❑ Other (Specify')
<br />Last, Suffix)
<br />Sb. UNDER 1 YEAR
<br />2, SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />(]' 00A,
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3, DATE Oi! Di
<br />Found S
<br />6, DATE OF
<br />Febru
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Home,
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />JoAnn b den.:
<br />12. MOTHER'SNAME (First,
<br />Mary Kocian
<br />14a. INFORMANT -NAME
<br />JoAnn Ruzicka
<br />lee. FUNERAL DIRECTOR SIGNATURE
<br />Stacie L Cook
<br />x .
<br />fi,1NEiL HONE NAME:Af: MAILING ADDRESS (Street, City or Town, State)
<br />4 i ;Faith Fai efat 140Fher 2929 S. Locust Street, Grand Island; :Nebraska for
<br />r ( Asq' 1,
<br />M. PART L inter th, tlwia
<br />respinitery irrgat/ or
<br />Ei:IA`lI 4UE4Fi
<br />ilieaa!a.tt::cond.Itlln reaull
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION,
<br />Central Nebraska Cremation Services
<br />:16b: LICENSE NO.
<br />1495
<br />Sf. ZIP CODE
<br />68801
<br />Suffix) If wife, give mall
<br />Middle, Malden Sumapte
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructitns and examples)
<br />wettdt• 4usaaas, (Nunes, or complieationsehat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />cuter f brlllatket without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on aline. Add additional lines if necessary.
<br />;a14lmeoiA` s CAUSE:
<br />Heart Complications
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Nit gon(58one, it b) '
<br />it ., amiin .:fo::tt* case. Bate
<br />on:Hna:i':
<br />the:l(NDitIt .YE40 CAUSE>
<br />:isesse Or injury that initiated
<br />Is resulting ind..th DUE
<br />fS;PART'a, tfTi4awe
<br />2O. Of:FEMALE:. .
<br />:.:'N::pfegPilt::vAfni)Id+!ltl
<br />Pwgnin tat tlnthsof 505th :;
<br />.... prsgnar; biit pregnent:Within 42 days or death
<br />Prognant, but pregnant 43 dayt to 1 year before death
<br />ripivifm:pragumnl w+Illif,jfre.Pea peer
<br />OR AS A CONSEQUENCE OF:
<br />AS A CONSEQUENCE OF:
<br />14b. RELATION
<br />SpQuee:`
<br />16c. DATE (Ito•
<br />Septem
<br />17bt
<br />ANT CONDITIONS -Conditions contributing to the death but not remitting iR the underlying cause given in PART I.
<br />All. O I1 JURY (MO
<br />rI-JyURY AT WORK?
<br />O> (Jay; Yr.)
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicido.
<br />❑ Accident ❑ Pending' Investigation..'
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />2ib.1PTRANSPORTATION INJURY
<br />.:. Driver/Operator
<br />:: 0 Paesenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />22c. PLACE OF INJURY -At home farm,>str
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />GAT i OF IN lURY;: STREET NUMBER, APT.NO.
<br />23a, DATE OF DEATH (Mo„ Day, Yr.)
<br />XIM ATESJO$EO(Mo.,Day,Yr.)
<br />® YE
<br />21c. WAS AN AU
<br />❑ YES
<br />21d. WEREAUTOP$Y'
<br />TO COMPI.ETE.C)
<br />❑ YES
<br />t, factory, office building, construct/
<br />CITY/TOWN - -STATE
<br />23c. TIME OF DEATH
<br />33d: T4104 0igtof:r»yknpwt{iga, teeth occurred at the time, date and place
<br />titte gi tha'ca iais) stated. (Signature and Title)
<br />ONTRIRUTE TO THE DEATH?
<br />PROBABj.Y E5 UNKNOWN
<br />2'f.i*ME> Tl kANDADORESS o CERTfFI R (Type or Print
<br />28a. HAS 0
<br />0 YES
<br />Ei
<br />E
<br />GAN'.OR.TISSUE DONATI.t' N:BEEN<CONSIDERED?
<br />.131.NO:::i
<br />Ian OSbor 'r1;a)rCounty Deputy Attorney, 231 S Locust St, Grand Island, Nebraska, 68801
<br />REGISTRAR'S SIGNATUR5
<br />24a. DATE SIGNED41o., Day, Yr.)
<br />y5eptember 2, 2025
<br />24 'RONOUNCED DEAD (Mo.,
<br />TIME
<br />24d. Ti
<br />c: ;P:. o., Day, Yr.)
<br />Septtmbtar 2, 2025
<br />24e; On the basis of examination and/or investigation, in my oP
<br />the time, date and place and due to the causes) stated. (SI
<br />Ian A Osborn, Hall County Deputy Attorney
<br />28b. WAS CONSENT'
<br />Not Applicable if 28a is NO
<br />. .
<br />28b. DATE FILED BY REGIST
<br />September 10,.2
<br />iy
<br />
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