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WHEN THIS COPY DES `THE RAI Ep SEAL OF THE NEBRASKA HEALTH AND HUMAN OERWCES f '
<br />SYSTEM,4T CERTFIES THE BELOW BKA,MUE COPY OF THE ORIG#JAL RECORD ON FILE WITH
<br />THE NEARAWA HEAL AND HYMMN' RVft$ SYSTEM WTAL t iAT1 *PI EV i 1
<br />_ -WICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL: �tECORDS. r.
<br />DATE OF ISSUANCE
<br />. COc9PER
<br />9/9/2004 200 '1410932 NLEY S..
<br />LINCOLN, NEBRASKA HEALTH AN1144& MAN SERVICES SYStEM
<br />STATE OF NEBRASKA DEPARTMENT OF HEALTH AND HUMAN $FRWCES FOMiNCEANETSUPPORT
<br />VITAL C'F.RTTFIC'ATF. OF 1)F.ATH -_ - 04 09223
<br />1. DECEDENT -NAME FIRST
<br />i MIDDLE LAST
<br />1
<br />2. SEX - ' -- 3: DATE OF DEATH tMonth. Day. Year)
<br />Barbara Jean
<br />,
<br />Zoucha
<br />Fe"klt'. ` 10 Adgus't --23, 2004
<br />i
<br />4. CITY AND STATE OF BIRTH lif not in U.S.A.. name countryl
<br />,y EXAMINER OR CORONER?
<br />Sa. AGE -Last Binhday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />St. Louis, Missouri
<br />tTJr1
<br />(Yrs.l
<br />63
<br />5b. MOS. DAYS
<br />5c. HOURS' MINS.
<br />June 29, 1941
<br />7, SOCIAL SECURTIY NUMBER
<br />I,.JyJ
<br />Be. PLACE OF DEATH
<br />❑
<br />❑
<br />486 -44 -8642
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />HOSPITAL: Inpatient OTHER' Nursing Home
<br />❑ ER Outpatient ® Residence
<br />8b. FACILITY -Name 71/not mstautm give street and number)
<br />581 E. 18th St.
<br />❑ DOA ❑ Other(Spec)fvt
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH
<br />l
<br />9a. RESIDENCE -STATE 9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including 00 Code,` 9e. INSIDE CITY LIMITS
<br />Nebraska Hall
<br />Grand Island
<br />581 E. 18th St.:68801 Yes [� No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY le,g.. Italian. Mexican. German, etc)
<br />12. ® MARRIED
<br />❑ WIDOWED
<br />13 NAME OF SPOUSE 11f wife. give maiden name)
<br />etc.) (Specify)
<br />White
<br />(Specify)
<br />American
<br />ARI NEVER
<br />DIVORCED
<br />Edwin Zoucha
<br />14a. USUAL OCCUPATION iGive kindot work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary f0 -12) College 11 -4 or 5.1
<br />of workfng life, even it retired)
<br />~ °
<br />Laundry -Cook
<br />°
<br />NE. Veterans Home
<br />Unknown
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />1 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Norval E.
<br />Burgess
<br />Viola
<br />Maxine Garvey
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.) (If yes. give war and dates of services)
<br />No --- - - - - --
<br />Edwin Zoucha
<br />19b. INFORMANT MAILINU AUUHGSJ IJ.- I- 1-. 1e.1 -ivv °,.,, -ur,
<br />581 E. 18th St., Grand Island, Nebraska 68801
<br />20. EMBALMER - SIGNATURE 8 LICENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME
<br />Ndt Embalmed ❑Burial El Removal Aug. 23, 2004 Westlawn Crematory
<br />22a. FUNERAL HOME -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H. ®Cremation ❑Donation Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. IMMED�IIA�TEE/�C�AU�SE J \^\ (ENTER ON N{E►,y AUS�E�R LINE FOR (a). (b). AND c)) �n� �r ` Init I bet /w gBn onset and death
<br />PART l s W/ �4rk _ 1 tX i N1� r. / ` �b �7/Y� • l W� � W ��/
<br />PA Ia1 1 d t9P.AM ,til1� AIYN Q_ll
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval6etween onset and death
<br />I
<br />Ibl --
<br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />I `
<br />I
<br />-OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS? I
<br />J.-
<br />,y EXAMINER OR CORONER?
<br />II
<br />(Ages 10 -54) Yes No
<br />Yes No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />7 Accident F Undetermined
<br />M
<br />El Suicide 7 Pending
<br />26e. INJURY AT WORK
<br />Lp
<br />26L office buQdinN INJURY %5 � ,farm, street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑ No ❑
<br />Vas
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />August 23,2004
<br />< ¢
<br />M
<br />$ v`-i
<br />� N °
<br /><�
<br />27b. DATE SIGNED (MO.. Day. Yr,)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yr)
<br />28d. PRONOUNCED DEAD (Hour)
<br />iJ
<br />gg0
<br />august 23,2004
<br />4- 10':50 am M
<br />EN
<br />�_��
<br />M
<br />27d. To the best of my know) e. death urred at th , date and place and due to the
<br />28e. On the basis of examination and, or investigation, in my opinion death occurred at
<br />~ °
<br />causelsl stated.
<br />°
<br />Me time, data and place and due to the causes) statetl.
<br />ISi nature and Ttlel 10
<br />(Signature and Title) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO TIM
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />YES ❑ NO NKNOWN
<br />I ❑ YES NO
<br />4_1 ❑ YES NO
<br />31.ry ArvUHUUMCDJVr VC ,, l r.,,°,.n., w.,..,..,. .,... ... .................. -- ...-., ,.,r- _........
<br />Dr.Ryan D Crouch DO rie 800 Alpha Grand Island NE 68803
<br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr)
<br />AUG 2 5 200
<br />THE WEST 16' OF LOT 10, ALL OF LOT 11 AND THE
<br />EAST 10 5/10' OF LOT 12, BLOCK 4, BLAIN ADDITION
<br />TO THE CITY OF GRAND ISLAND, HALL COUNTY, NEBRASKA
<br />
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