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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 ORIGINM'--RECOFiD-DN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sTAti5t/CSSEtTu:)N;~WHICH IS
<br />
<br />:::;::~~:::::~TORY FOR VITAL RECORDS, l7.'""V--Z ~~-.f-t;;-..-' '.CO'.. ~fq.>.'::.~'~
<br />MAR 0 4 2005 E1'J~'~"-~t~1vf~'(~'ttdQPER
<br />LINCOLN, NEBRASKA 2 0 0 6 0 13 5 1 ~~~srl:;a~~m~;fs~:~~~~
<br />
<br />----
<br />~
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUf'f'OFf(O 5 0 2 2 3 0
<br />CERTIFICATE OF DEATH
<br />___.... '~~~,... .....n
<br />
<br />Middle,
<br />John
<br />
<br />LaSl,
<br />Reitan
<br />
<br />SUffix)
<br />Jr.
<br />
<br />2, SEX
<br />Male
<br />
<br />3, DATE OF DEATH (Mo_, Day, Yr.)
<br />___ ~ebruary 21, 2005
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />
<br />5a_ AGE-Last Blrlhday
<br />(Yrs,) 77
<br />
<br />Sb_ UNOER 1 YEAR
<br />MOS, OAYS
<br />
<br />50, UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 23, 1927
<br />
<br />7_ SOCIAL SECURITY NUMBER
<br />507-24-2675
<br />
<br />8a, PLACE OF DEATH
<br />HiliiflIAl.: 00 InpallelH
<br />- 0 ER/oii!iialleiii
<br />
<br />QlliE8: 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />. 1:\.h........EAG.!!LY:NAllf__ ~H,. not !11~.tit!..!tiOti. .tl\l.e_.Sl!e.fL1tru:L!lli~~
<br />
<br />--0 Decedenf'.Homa-
<br />
<br />St. Francis Medical Center
<br />
<br />U [l)I\'
<br />
<br />o Olhar (Spacify)
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />68803
<br />
<br />Bd_ COUNTY OF DEATH
<br />Hall
<br />
<br />ga, RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b_ COUNTY
<br />Hall
<br />
<br />
<br />gg, INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />"d
<br />i=I
<br /><0
<br />H
<br />(I)
<br />H
<br />
<br />91. ZIP CODE
<br />
<br />2203 West Oklahoma 68803
<br />
<br />lOa, MARITAL STATUS AT TIME OF DEATH iXMarrled 0 Navar Married 10b_ NAME OF SPOUSE (First, Middle, Last, Suffix) II wile, giva maidan nama_
<br />
<br />U Married, bUl.eparaled 0 Widowed 0 Divorced 0 Unknown Mary Zieg
<br />
<br />11, FATHER'S-NAME (Flrsf, Middle,
<br />Clarence
<br />
<br />Lasl, Suffix)
<br />Reitan
<br />
<br />12_ MOTHER'S.NAME (Flrsl,
<br />Martha
<br />
<br />Middle, Melden Surname)
<br />
<br />Mcl:I,g.~,=~__
<br />14b, RELATIONSHIP TO DECEOENT
<br />
<br />Wife
<br />
<br />'lj
<br />i=I
<br /><0
<br />H
<br />~
<br />4-4
<br />o
<br />;;>-,
<br />.I--J
<br />.,..,
<br />U
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dates of service if yes, 14a, INFORMANT-NAME
<br />(Yes, no, or unk) Yes: 6/20/45 8/5 / ~~___~!!.~L~~i~?l1.__
<br />15, METHOD OF DISPOSITION 16a, EMBALMER-SIGNATURE
<br />cIBurial 0 Donation __~ ~
<br />
<br />IJ Cremallon LJ Entombment
<br />
<br />l6d, CEMETERY, C EMATORY OR OTHER LOCATION
<br />
<br />16b. LICENSE NO.
<br />'*" /~;(.S-
<br />CfTY /TOWN
<br />
<br />16c, DATE (Mo" Day, Yr,)
<br />February 24, 2005
<br />
<br />STATE
<br />
<br />"
<br />i=I
<br />o
<br />.,..,
<br />(I)
<br />.,..,
<br />;>
<br />,,..,
<br />"d
<br />,.c
<br />::l
<br />Cf.l
<br />"d
<br />i=I
<br />o
<br />u
<br />Q)
<br />Cf.l
<br />
<br />o Removal 0 Olher (Specify)
<br />
<br />Grand Island Cemetery,
<br />
<br />Grand Island,
<br />
<br />Nebraska
<br />
<br />..-,....----...---..
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Slraal, Cily or Town, Slafa)
<br />Apfd-.:.F~DetaLHQm:e, 112;1 W. Se.~alld, Grand Island, Nebraska
<br />
<br />17b_ Zip Code
<br />68801
<br />
<br />PART I. Enter fhe ch~ln 01 evan15--dlseases, Injuries, or complicaUons--that dlreclly caua.d Ih. death, DO NOT anfer t.rminal av.nts such as cardiac arrest,
<br />respiralory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one causa on a line. Add additlonalllnes If necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />._,
<br />
<br />
<br />l,-~,
<br />
<br />I
<br />I
<br />
<br />I onset to death
<br />I!"""")()
<br />JI.> {/v....-,'P
<br />- ""'.""'._'''''_.'~___',''.__'____ o.
<br />I onset to death
<br />
<br />I '7 ~
<br />--; on::fo d~;;;--~P--
<br />
<br />I P'
<br />
<br />I
<br />I
<br />I on.ello death
<br />I
<br />I
<br />
<br />SeqUi:!ntlally list conditions, If
<br />.ny, I.adlng 10 th. ceus.llat.d
<br />on line a,
<br />Entar Iha UNDERLYING CAUSE
<br />(dls.... or Injury Ih.t Inlllated
<br />the evenls resulting In death)
<br />IA';IT
<br />
<br />(a)
<br />DUE TO, 0 AS A CONSEQUENCE OF:
<br />
<br />~""o:%~\f~( ~
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />-~
<br />
<br />IMMEDIATE CAUSE (Final
<br />dls@aseorcondltlonresultlng
<br />In d.eth)
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITlONS.Condifion, conlributing fo the dealh but not resulling in the underlying causa givan In PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />W YES NO
<br />
<br />20, IF FEMALE;
<br />o NOI pregnanf wllhln paSf year
<br />o Pregnant at time of death
<br />o Not pregnanl, but pragnant within 42 days of dealh
<br />o NOI pregnant, but pregnant 43 days to 1 year before death
<br />U Unknown if pregnant wllhln Ihe past yaar
<br />
<br />21~NER OF DEATH
<br />~alUral 0 Homlclda
<br />
<br />o AccldenlD Pending Investigallon
<br />
<br />21b_tFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY ERFORMED?
<br />o Drivar/Op.ralor
<br />o YES ~O
<br />o Passenger /'"\"
<br />
<br />o Sulclda 0 Could nof be defermlned
<br />
<br />o Pedestrian
<br />o other (Specily)
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />o
<br />ID
<br />~
<br />
<br />DYES
<br />
<br />UNO
<br />
<br /><2a. U~;_::~:U~Y ..1:' ~_a~L)____. 1"1), liME OF ii'J0t\~J: ~LAGE Or 'NJURV~At_~o_~e, larro, SlrAal, ,."ory, olliea bUilding, construc":~~'te,.t:~:~:OlfY)
<br />
<br />
<br />22d_INJURY AT WORK? 22._ DESCRIBE HOW INJURY OCCURRED
<br />
<br />(I)
<br />H
<br />Q)
<br />"d
<br />l-4
<br />o
<br />U
<br />Q)
<br />p::j
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />CITYIfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE;
<br />
<br />24a, DATE SIGN~D (Mo_, Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />,.~ ~
<br />,D~c:
<br />H~
<br />Q..a. ;q: :::J
<br />!i~c~
<br /><>wZ
<br />1lZ=>
<br />00
<br />f2c:O
<br />85
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />249. On Ihe basis of exarnlnalion and/or InvestIgatIon, in my opinion death occurred at
<br />the lime, dale and place and duelo Ihe causa(s) slated. (Signefure and Tille) "
<br />
<br />25_ DIDTOBACC' CONTRIB ETOTHE D ATH? 26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b, WAS CONSENT GRANTED?
<br />
<br />DYES \Y'NO 0 ROBABLY U UNKNOWN 0 YES .~O NOI Applicabla i~26ais NO 0 YES
<br />2i-NAME,TritfAND ADURESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COLlmYATroRNEYliTypa or Prinf)
<br />Gordon Hrnicek M.D. 729 N. Custer, Grand Island, NE. 68801
<br />
<br />NO
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b_ DATE; FILED BY REGISTRAR (Mo.. Day, Yr,)
<br />
<br />MAR
<br />
<br />2 2005
<br />
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