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<br />200512481
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOAT",) 19-151
<br />CERTIFICATE OF DEATH \..J F
<br />
<br />1. DECEDENT'S.NAME IF"'I. Mlddlt. laot, Sull"I' 2. SEX
<br />
<br />J h Louis Jelinek Male
<br />"', I
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH i 50. AGE.liS' B".May , 5b. UNDER 1 YEAR i 5<. UNDER t DAY
<br />
<br />; (Yr..) ! MOS, DAYS: HOURS MINS
<br />
<br />J. DATE OF DEATH (Me" Day, Y'.I
<br />November 14, 2005
<br />
<br />S. DATE OF BIRTH IMe" Doy. Yr.1
<br />
<br />Farwell, Nebraska
<br />
<br />80
<br />
<br />October 30, 1925
<br />
<br />
<br />
<br />lilt. PlACE OF OEATIi
<br />
<br />, t:t.C.5.f.IIAL.:
<br />i
<br />I
<br />i
<br />I
<br />
<br />~ Inpatient
<br />
<br />Qne!: ~ Ntnlng HOrnlotTC ~ HeSpice FOClhty
<br />
<br />7 SOCIAl SECURITY NUMBER
<br />
<br />506-28-0925
<br />
<br />Sb. FACIliTY-NAME (II no. In.titutien. glYO .lreOl ond numberl
<br />
<br />~ ERiOulpo"en.
<br />
<br />o Oecl<ltm'._
<br />
<br />68105
<br />
<br />o !Xl' U Olhe< 1$pecJfy1
<br />!8d. COUNTY OF DEATH
<br />i Doug1 as
<br />
<br />8(:. CITY OR TOWN OF DEATH Ilnclude Zip Cede,
<br />
<br />4005 Mason Avenue
<br />lOa. MARITAl STATUS AT TIME OF DEATH lAIarried 0 Never Married
<br />
<br />a Marrild. but .eperated 0 Widowed [J D",orCld 0 Unknown
<br />
<br />I 9UIP CODE
<br />I 68803
<br />
<br />lOb. NAME OF SPOUSE (Firot. Middll, lasr, sum.) If wlfl, g"'" mlidln namo_
<br />
<br />
<br />9g, INSIDE CITY liMITS
<br />~ YES [J NO
<br />
<br />lit> COUNTY
<br />Hall
<br />
<br />Betty DeMary
<br />
<br />11. FATHER'S-NAME (Fir$!.
<br />
<br />Middle,
<br />
<br />liSl,
<br />
<br />SUfli.)
<br />
<br />112. MOTHER'S-NAME (Firsl. Middle, Maidon Surname)
<br />I Alice V. Novak
<br />'~'-~.~~~-'_.~~
<br />I t4b. RelATIONSHIP TO DECEDENT
<br />I
<br />I Wife
<br />
<br />o . ek
<br />t3. EVER IN U.S. ARMED FORCES? Give dalo. of .ervice ~ yes. aa.INFORMANT-NAME
<br />rNs86orUnk) WWll 6/14/44 - 6/7/4 Bet Y Jelinek
<br />
<br />lSa. EMBAlMER.SIGNATURE
<br />
<br />
<br />16b. liCENSE No.wf$:;
<br />
<br />
<br />CITY I TOWN
<br />
<br />'.~"'~-
<br />i l$c. DATE (MO.. Dey, Yr. ) I
<br />I November 18, 2005 i
<br />STATE
<br />
<br />[J Cremallon [J Entombment
<br />i
<br />[J Removal [J O1IIor (Specify) I
<br />_ I Grand Island Cemetery
<br />t7.. FUNERAL HOME NAME AND MAiliNG ADDRESS (StreOl, City or Town, Stalll
<br />Apfel Funeral Home, 1123 West Second, Grand
<br />
<br />t6<l CEMETERY, CREMATORY OR OTHER lOCATION
<br />
<br />Grand Island, Nebraska
<br />t 7b. ZIP Code
<br />, 68801
<br />
<br />IMMED4ATE CAUSE:
<br />
<br />on...lIp dlall1
<br />
<br />~ Respiratory failure
<br />DUE TO, ~ AS A CONSEQUENCE OF:
<br />
<br />hours
<br />
<br />, ...... to dlalll
<br />
<br />~1IIl"'--"
<br />IIIJ. -....lI1I_....
<br />.......
<br />_.. UNJERlYJIG CAIlIIE
<br />(-Qf"*,,,-~
<br />..-.-..~-,
<br />LMI'
<br />
<br />~ Aspiration pneumonia
<br />
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />months
<br />
<br />onset lP dOam
<br />
<br />(c) Vomiting
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />minutes
<br />
<br />onset .. dlall1
<br />
<br />(eI)
<br />
<br />[J AccidantO Pending Investigalien
<br />IJ Suicide [J Could not be detarmined
<br />
<br />i t9. WAS MEDICAl EXAMINER
<br />I
<br />I OR CORONER CONTACTED?
<br />~ YES IJ NO
<br />
<br />21b, IF TRANSPORTATION INJURY I 2tc. WA~ AN AUTOPSY PERFORMED?
<br />[J OrivoriOperator I
<br />[J P.....nger [J YES '" NO
<br />
<br />18. PART II, OTHER SIGNIFICANT CONDITIONS-Condltiona COnlrrbullng to tha death bu. not re.ullln9 in the underlying cau.a given in PART i.
<br />
<br />disease
<br />
<br />IJ Net pragnanl within past year
<br />[J Pragnant allime of dealll
<br />IJ Not pragnanl, but pregnanl with,n 42 days 01 de.th
<br />[J Nol pragoant, bul pregnant S3 days 10 1 year before deall1
<br />IJ Unknown if pregnant within Ihl paat year
<br />
<br />21a. MANNER OF DEATH
<br />!I Natural [J Homicoda
<br />
<br />[J Pedestrian
<br />[J Oth.r (SpecIfy)
<br />
<br />-~
<br />
<br />21d_ WERE AUTOPSY FINDlNGS AVAll.Alll.E TO
<br />
<br />COIoI'l.ETE CAUSI: OF DEATH?
<br />[J YES IJ NQ
<br />
<br />-~_.~
<br />
<br />a YES [J NO
<br />
<br />
<br />22a. DATE OF INJURY (Me" Day, Yr.)
<br />
<br />22tl. TIME OF INJURY 22c. PLACE OF INJUIlY-AI heme, farm, aUall, factory, oNica building, conauuclion aile. IIc.ISptClty)
<br />m
<br />
<br />22f.lOCATION Of INJURY. STREET & NUMBER, APT. NO.
<br />
<br />ClTYITONN
<br />
<br />SIRE
<br />
<br />ZIP cooe
<br />
<br />238. DATE OF DEATH (Mo.. Day, Yr.)
<br />
<br />248. DATE SIGNED (M<>" Day, Yr.)
<br />
<br />2-lb. TlME OF DE.m1
<br />
<br />230. TIME OF DEATH
<br />5:05 a.m
<br />
<br />illl~
<br />:1'
<br />
<br />m
<br />
<br />24<:. PRONOUNCED DEAD (M<>" Day, Yr.) ; 204d, TM PRON:llIICED DEAD
<br />I m
<br />
<br />23d. TO ~ boa' 01 my kIIOwItClga, dlall1 cccurred .llIla timo, \late and pIKa
<br />and due to ~ ca~al.taled. (Sigrlaturt and Til") "
<br />
<br />.' c...v:-
<br />
<br />2... On ~ basil of ..amma'ion and/or InVealigation, '" my "'*- diem occurred at
<br />~ "ml, dale .nd place and due to Ihe cauae(.) stated. (Sognaturl and TI1" ) "
<br />
<br />'I' 2Sa. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? i 26b. WAS CONSENT GRANTED?
<br />
<br />[J YES lClNO [J PRCl8ABlY [J UNKNOWN IJ YES iJ NO I Net Applicabll.f 28a ia NO IJ YES 0 NO
<br />%1_ NAME. TITlE AND AOORESS Of CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY AnORNEY) (Type or Pnnt)
<br />William Es 1in. M.D., VA Medical Center 4101 Woolworth Avenuea Omaha. NE 68105
<br />
<br />
<br />-~ fwNf
<br />
<br />28~. DATE FilED 8Y REGISTRAR 1M<>.. Day, Yr.)
<br />
<br />.NOV 2 1 2005
<br />
<br />I '~. 'J.~~ '
<br />~' vi '.
<br />This cert'ifi~th~.i..doc~~.e~fo b~'~~. copy of an original record on file with Vital Statistics, Douglas Co~nty
<br />HeaJ'!h Dr!pi,/O~a, ~br3.ih, ~e(tjfi~d copies must have a raised seal in the area to the left, ReproductIOns
<br />oft~ls~n.~ertl~te are n~e~a~Ples.
<br />,'t:o I'A ,/"-.
<br />Date Issued:->' . NOV 2 1.28:t\
<br />F .... ~
<br />.-( (;., ,'" ("'i" \~
<br />-"'1'\ j j,"
<br />
<br />Registrar:
<br />
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<br />
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