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WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND SYSTE?4 R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS THE LEGAL DEPOSITORY FOR VITAL RECORDS. I DATE OF ISSUANCE MV 8 2001 200112807 ASS /S€ LINCOLN, NEBRASKA HEALTH AND HUM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER VITAL STATISTICS CERTIFICATE OF DEATH -= =1 11927 1. DECEDENT - NAME FIRST MIDDLE LAST 2 SEX -- '¢ TEOF DEATH fM-111 Day. Vaar) Zella Francis Klinkacek Female October 18 2001 4. CITY AND STATE OF BIRTH lllnot in USA.. name country; 5a. AGE - Last Bmhday UNDER 1 YEAR UNDER / DAY 6, DATE OF BIRTH fMOnth. Day. Year) MOS. I DAYS Sc. HOURS MINS. (Vrs.l Sb. Hazard Nebraska 74 December 9 1926 7, SOCIAL SECURITY NUMBER 8a PLACE OF DEATH HOSPITAL. ❑ Inpatient OTHER ❑ Nursing Home 507 -92 -2858 ❑ ER Outpatient © Res,dence 8b. FACILITY - Name (N not mshfution, give street and number ❑ DOA ❑ Olher (spec,ty - 406 W. Medina Street 6c CITY TOWN OR LOCATION OF DEATH 80 INSIDE CITY LIMITS 8e COUNTY OF DEATH Caro Yes ® No ❑ Hall 9a. RIWDENCE -STATE 9b. COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER (!,eluding Lp Cpde) 9e INSIDE CITY LIMITS Nebraska Hall Cairo 406 W. Medina St. 68824 Yes [j No El 10. RACE - leg, White. Black. American Indian. 11. ANCESTRY le g.. Italian. Mexican. German. etc) 12 ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE (If wde owe maiden name/ etc l ISDecdyl White (Specify) American NEVER DIVORCED MARRIED Lester Klinkacek 14a. USUAL OCCUPATION /Gore kindot work done during most tdb KIND OF BUSINESS INDUSTRY 15 EDUCATION (Spec tv only - ,ghest grade completed) of working life. even d refired) Elementary or Secondary LO 12) College 14.x' ' Housewife Own Home 1 12 16. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Ray Smith Fannie known _ 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19, INFORMANT - NAME 1 (Yes . no or unk.l (if yes, give war and dates of servlcesl No I Le q t 1, r K 1 ' n 1, 1 - 19b INFORMANT MAILING ADDRESS (STREET OR R.F D NO.. CITY OR TOWN STATE. ZIP! 406 • Medina Street - Cai NE - -- 20. EM E SIGNATUR ICENSE NO 21a METHOD OF DISPOSITION 21b DATE 21c. CEMETERY OR CREMATORY NAME 9 1 O a Bunal ❑Removal Zion Lutheran __ Qqt. 22, 2001 22a FUNERAL HO --NAME 21d CEMETERY OR CREMATORY LOCATION CITY OP TOWN STATE ❑ Crematwr ❑ Dona, °n Buffalo O Rasmussen Mort ar - 22b. FUNERAL HOME ADDRESS (STR ET OR R.F.D NO. CITY OR TOWN. STATE, ZIP) 311 Grand Avenue - Ravenna, NE 68869 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR 1al. (b). AND (cl) Interval between onset ane dear - PART (a) DUE TO, OR AS A CONSEQUENCE OF Interval between onset and dear fbI DUE TO OR AS A CONSEQUENCE OF Interval between onset and oe- (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL OR CORONER' PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER II (Ages 10 -541 Yes No Ves No Ye5 No 26a. 26b. DATE OF INJURY (Mo., Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident 0 Undetermined M _ Suicide F-1 Pending 26e. INJURY AT WORK 261. PLACE OF - At home, farm, street factory 269. LOCATION STREET OR A.F.D. NO CITY OR TOWN $TAT= Homicide Investigation No Yes ❑ No ❑ (Specify) o I ce building etc (Speci 27a. DATE OF DEATH (Mo. Day Yr) 28a DATE SIGNED iMO.. Day Vcl 28b TIME OF DEATH r -w J 1 2: 00 am M n a 27b. DATE SIGNED (Mo,. Day. Yr) 27c, TIME OF DEATH 28c. PRONOUNCED DEAD /Mo.. Day, Yr) 28d. PRONOUNCED DEAD (HOUrI a � �y go M �' w z _ M 8 .- ° o ° 27d To the best of my knowledge . death occurred at the time, date and place and due to the m my opinion death occurred at 28e. On the basis of examination andror the cause)sl stated. causelsi the time. date and place and tlu he causelsl stated. (Si nature and Title) (SI nature and Title) 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH' 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED' ❑ YES ❑ NO ff] UNKNOWN ❑ YES FK1 NO ❑ YES ® NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY, !Type p Printl Deputy Webb H SO 1 Locust, Grand Is land. NE 68801 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR JMo., Day. Yr.) OCT 9 - J