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X m CA c �-� cn o D� _ C= N =3 r } CD C C�fi O -n C D S2. �' C.J'1 � � N rrt CD co D f� ` m. � r C/) F-A j CD D co .. , ca CID G3 \� CA III \ t� WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SER SYSTEA4 IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL-RECD_BD_6AtRLE THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAF( WS`, =Tfle&_." THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 200201393 jU/l. G6 OCT 2 5 2001 ,A STA LINCOLN, NEBRASKA HEALTHA)W 140MAN.SERVY&OSi STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN Sjj3h AAICE_ 4 vrrAL sTAnsncs CERTIFICATE OF DEATK-> IS, SUPPORT 011 x.1777 t DECEDENT - NAME FIRST MIDDLE LAST 2 SEX 3 DATE OF DEATH /Month. Day Year) Joseph Alois Ruzicka Male October 14, 2001 4. CITY AND STATE OF BIRTH lUnotin USA, name country) 5a. AGE - Last Birthday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIRTH /Month. Day. Year) Loma, Nebraska (Yr, 87 5b. MOS I DAYS 5c HOURS MINS O I July 8, 1914 7 SOCIAL SECURTIY NUMBER Ba. PLACE OF DEATH 507 -42 -2680 HOSPITAL ❑ Inpatient OTHER ® Nursing Home ❑ ER Outpatient ❑ Residence 8b FACILITY -Name (If not mstaution, give street and number) Tiffany Square Care Center ❑ DOA ❑ Other(Specdvl Bc CITY TOWN OR LOCATION OF DEATH Bd INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island Yes ® No ❑ Hall 9a RESIDENCE STATE 9D COUNTY 9c CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Code/ 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 519 Kennedy Dr. 68803 Yes ® No ❑ 10 RACE - (eg.. White. Black. American Indian 11. ANCESTRY le. g.. Italian, Mexican. German. etc) 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE Ill wile, give maiden Hamel etc) Soec,fyl White ISpecityl Czech I NEVER DIVORCED MARRIED Helen M. Jank 14a USUAL OCCUPATION /Give kind of work done during most 14th KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specity only highest grade completecil Elementar or Secondar 10 -12) College 1 4 or n • I of working life. even If retired) Farmer Agriculture 8t�i Gra e 16 FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Alois Ruzicka Mary Coufal 18 WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT NAME (Yes no or unk I III yes give war and dates of services) No - - - - - -- I Helen Ruzicka 19b INFORMANT MAILING ADDRESS (STREET OR R D NO CITY OR TOWN. STATE. ZIP) 519 Kennedy Dr., Grand Island, Nebraska 68803 20 ALMER - SIGNATURE 8 LICENSE NO 21a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME it, �. // ©Bunal ❑ Removal Oct. 19, 2001 Westlawn Memorial Park 22a FUNERAL HOME -NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livin stop- Sondermann F.H. ❑Cremation ❑°°nation Grand Island, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP( 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23 IMMEDIATE CAUSE (ENTER O Y ONE CAUSE PER LINE FOR lal. Ib), (c)I fnte; I between onsel and seam PART (� I ..� C) —.fit lal � `Y C.' � � I DUE TO. OR AS A CONSEQUENCE OF \ Interval between onset and dean I DUE TO. OR AS A CONSEQUENCE OF Inlery between onset and death I I (c) I OTHER SIGNIFICANT NDITIONS - Conditions contributing to th death but not elate n PART PART 1 PREGNANCY It IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS? ,�— 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER' II f V� (Ages 10 -54) Yes No Yes No Yes N 26a. 26b DATE OF INJURY JAW, Day. Yr.) 16: HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident ❑ Undetermined M Swede ❑ Pending 26e INJURY AT WORK T26f . PLACE OF INJURY - At home. farm, street. factory 26g LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE Homicide investigation ❑F—] Yes No ❑ office building. to ISpeciN) 211ia. DATE OF DEATH /MO Day. Yr.) 28a DATE SIGNED (Mo. Day. Yr] 28b TIME OF DEATH � October 14, 2001 > <Q M H V i > 27th. DATE SIGNED /MO.. Day Yr) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD (MO.. Day. Yr.J 28d. PRONOUNCED DEAD (NOUrI FO October 22 20(il 04:45 AM a g ¢ M S g 28e. On the basis of examination and or investigation, in my opinion death occurred at a 27d. To the best of my knowledge death occurred at the ti e. date and pla nd due to the T e ° ° . l causes) stated. / (�-- ° the time, date and place and due to the causes) stated. C•-'`- �l-C. • (Signature and Title) ► Is nature and Title) ► 29. DID TOBACCO USE CONTRIBUTE TO T DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 3,0r.b� WAS CONSENT GRANTED? F-1 YES ❑ NO ,/ UNKNOWN ❑ VES NO 1 ❑ YES NO 37. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Print) XWilliam J.. Landis, NID 2444 4,Faidlei, rand Island NE 68803 32a. REGISTRAR 32b DATE FILED BY REGISTRAR (Mo., Day. Yr.) 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