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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL A1;P9RJl.-f}t'l FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATls7'if:s~SGeT/;t:tNi.wI:lICH IS
<br />
<br />:::::::::~:csr;RY FOR WYAL RECORDS. 6z!~f!tkR
<br />
<br />SEP 0 6 Z005 2 0 0 51 2 4 3 0 4SSI$TA'NT-SrAiEREG)ST1!~R
<br />LINCOLN, NEBRASKA HBAiti'L4ND HUMAN S~RVICEs
<br />- -~.t'-.~~~f_:F~~~~-~-" ,.
<br />
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<br />
<br />1
<br />
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<br />,~~~~~OFNEBR~S_~:_~_~~PAR~~~;rF~~~~~N~~U~~~~~VI~~8FI~:N,CE-1\NDSq~~Rb:5' 09735
<br />
<br />DECEDENT'S.NAME (Flrsl, Middle, La.l, Suffix) 2, SEX 3, DATE OF DEATH (Mo" Day, Yr,)
<br />Mattie Ethel Link Xemale__. Au&~~t 25!.__20Q5
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE.La.1 Blrlhday
<br />(Yrs,)
<br />
<br />5b, UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c, UNDER 1 DAY
<br />--. ,. ~"_. _._'._','-'~~"-".
<br />HOURS MINS.
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />FACILITY, NAME (II not InslllUtlon, give street and number)
<br />
<br />90
<br />'-.1. 8a, PLACE OF DEATH
<br />~:
<br />
<br />.
<br />March 7, 1915
<br />
<br />Plainfield, New Jersey
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />151-26-1949
<br />
<br />o Inpallent QJJ:IEB:
<br />
<br />LX Nursing Home/LTC 0 Hospice Facility
<br />
<br />o ER/Outpatlent
<br />
<br />o Decedent's Home
<br />
<br />}iffany Square
<br />80, CITY OR TOWN OF DEATH (Include Zip Code),
<br />Grand Island 68803
<br />
<br />0001.
<br />
<br />o Other (Specify)
<br />
<br />8d, COUNTY OF DEATH
<br />Hall
<br />
<br />9a, RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b, COUNTY
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />_~~~~C~:Y~i~~;_
<br />
<br />9d. STREET AND NUMBER
<br />Lakewood Drive
<br />
<br />lOb, NAME OF SPOUSE (First, Mlddlo, l,sl, Sulllx) II wife, glv. m.iden name,
<br />
<br />o Merrled, bul separaled 0 Wldowad 0 Divorced 0 Unknown
<br />
<br />Salvatore Link
<br />
<br />11, FATHER'S-NAME (First,
<br />George
<br />
<br />Middle,
<br />Henry
<br />
<br />L.st, Suffix)
<br />Hantke
<br />
<br />12, MOTHER'S-NAME (Flrsl,
<br />Bessie
<br />
<br />Middle,
<br />Mae
<br />
<br />Malden Surname)
<br />Blair
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give deles 01 service II yes, 14a.INFORMAN1-NAME
<br />
<br />_..(Y~s,~o.:3~~l_ ~ _ Gary Pederson
<br />15 METHOD OF DISPOSITION ]6a~~lMER_SIGN 1(\ ( /.
<br />-& Burl.t 0 Don.I1on ~.-nv1 _, G-/ __ -:d/1d t1
<br />
<br />o Cremellon 0 Entombment 18ft CEMETERY, CREMATORY OR OTHER LOCATI
<br />
<br />o Removel 0 Olher (Specify)
<br />Garden of Memories Cemetery
<br />_._-~- -- ---
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, SI.le)
<br />
<br />CITY /TOWN
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Son
<br />16c, DATE (Mo., D.y, Yr,)
<br />Sept. 1. 2005
<br />STATE
<br />
<br />
<br />16b LICENSE NO,
<br />1071
<br />
<br />Paramus
<br />
<br />IMMEDIATE CAUSE (Final
<br />d1SI!!I!81!!1 Df condition resulting
<br />In demh)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />0---eyf'
<br />
<br />I
<br />I
<br />
<br />I onset 10 death
<br />I
<br />I
<br />
<br />L_.,_
<br />t onset to death
<br />I
<br />I
<br />I
<br />I onsel 10 death
<br />I
<br />I
<br />I
<br />
<br />respiratory erresl, or ventricular flbrlllallon without showing the ellology, DO NOT ABBREVIATE, Enler only one oause on a line, Add addltlonel lines II necessary,
<br />
<br />
<br />::MEDIATECr: -~j)
<br />
<br />Sequenllatly 11.1 condlllon., II
<br />IlIny, leading tD the c8usellsted
<br />on line a.
<br />Enter!h. UNDERLYING CAUSE
<br />(dl..a.e or Inlury that Initialed
<br />Ihe events re.ultlng In death)
<br />lA';T
<br />
<br />(bl
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />on,el to dealh
<br />
<br />(d)
<br />
<br />PART II, OTHER SIGNIFICANT CONDITIONS-Condlllons conlrlbullng 10 the death but nol resulting In the underlying cau,e given In PART I.
<br />
<br />20, IF FEMALE;
<br />)l('NOI pregnant within pasl year
<br />o Pregnanl al time of dealh
<br />o Nol pregn.nl, but pregn.nl wilhln 42 day' 01 dealh
<br />LJ Nol pregnant, but pregnant 43 days 10 1 year before death
<br />o Unknown II pregnanl within lha pa~l ye,u
<br />
<br />21e, MAf(NER OF DEATH
<br />~atu'el 0 Homlolde
<br />
<br />o Accldenlo Pending Invesllgalion
<br />
<br />o Sulclda 0 Could nol be detarmlned
<br />
<br />21b, IF TRANSPORTATION INJURY
<br />o Drlver/OperelOr
<br />
<br />o paasenger
<br />
<br />o PedeSlrlan
<br />
<br />o Other (Spoclfy)
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES J1<NO
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />DYES
<br />
<br />~O
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAilABLE TO
<br />COMPLETE CAUSE OF DEATH'
<br />DYES 0 NO
<br />
<br />220, DATE OF tNJURY (Mo" Day, Yr,)
<br />
<br />2211, TIME OF INJURY 22., PLACE OF INJURY,At home, I.rm, .Iroot, factory, ofllce building, con'lruClIon slle, elc. (Spoclly)
<br />m
<br />
<br />CITYfTOWN
<br />
<br />STI'JE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />August 25, 2005
<br />
<br />23c, TIME OF DEATH
<br />7:15 pm
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />/I, II ,
<br />
<br />~~~
<br />n~
<br />a.D.. 4:!( ~
<br />EUJ2:z
<br />8ffizO
<br />llZ=>
<br />00
<br />~a:O
<br />815
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basIs of examlnallon and/or investigation, In my opinion dealh occurred at
<br />Ihe lime, date and piece and due to tho c.us.(.) .t.ted. (Slgn.lure and Tille) "
<br />
<br />28., HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />28b, WAS CONSENT GRANTED?
<br />Not Applicable if 26~ Is NO 0 YES 0 NO
<br />Island, Nebraska 68803
<br />
<br />o YES NO 0 P ABLY 0 UNKNOWN _~~,~_~,,,,...__,_,_~O
<br />27, NAME, TIT A ADDRESS OF CERTIFlm ~HYSICIA~COf!QNER'S.fHYSICIAN OR COlj.NTY ATTORNEY) (Type or Prlnl)
<br />Gordon Hrnicek M.D 72~ N. cUster Avenue Grand
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />26b, DATE FilED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />SEP ~1 2005
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