|
<br />(?
<br />
<br />
<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 RECDRl1:QNc.BLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS:1fJitj~sEttrf!J!io.'Wl'!u;HIS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~..y. ,.,1.:1;lr~ -=:{\~;jJd-~.~:. >. ,:.~~='='_~.
<br />
<br />DATE OF ISSUANCE ~~"fftj'/J,"~
<br />
<br />OCT' 2 8 2005 20060 1912 A~~rANl::k-lig~%t
<br />LINCOLN, NEBRASKA HEJt~tH~D H~~;l!:tjif~#s
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANaE ANDsuf'",cim~; '. -- ~.
<br />_______ CERTIFICATE OF DEATH _ "', '~"7~"'}~ ~ ="c-
<br />
<br />333
<br />
<br />(First,
<br />L.Vella
<br />
<br />Middle,
<br />Sebesta
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />2,SEX
<br />Female
<br />
<br />':a-: El'ATE- OF DEATH (Mo" Day, Yr,)
<br />August 18, 2005
<br />
<br />Aurora, Nebraska
<br />
<br />5a_ AGE-Lasl Birthday
<br />(Yrs,)
<br />74
<br />
<br />5b, UNDER 1 YEAR
<br />MOS, DAYS
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />4, CiTY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />September 9, 1930
<br />
<br />7_ SOCIAL SECURITY NUMBER
<br />508 30 8672
<br />
<br />Ba. PLACE OF DEATH
<br />HOSPITAL: i1lnpallenl
<br />
<br />~: 0 Nursing Home/LTC 0 Hoapice Facility
<br />
<br />6b, FACILITY-NAME (It nol Inolltulion, give slreel and numbor)
<br />
<br />o ERIOulpatlenl
<br />
<br />o Decedont's HomO'
<br />
<br />St. Francis Medical Center
<br />
<br />Ot:O\
<br />
<br />o Olher (SpeCify)
<br />
<br />8d, COUNTY OF DEATH
<br />Hall
<br />
<br />Nebraska
<br />
<br />9d, STREET AND NUMBER
<br />41 Venus
<br />
<br />I ~'COUNTYH:~~-
<br />
<br />-. --I 9~-6ITYORTOWN Alda
<br />
<br />. .....-...---.--.---.--J...- ------~
<br />90. APT, NO gl. ZIP CODE
<br />68810
<br />."."., ,,",'..."...,.----.--
<br />10b, NAME OF SPOUSE (Flrsl, Middle, Last, Suffix) If wife, give maiden nemo,
<br />
<br />'.-'''] 9g...'.iN.. SIDE CITYLlMITS
<br />
<br />I!CI YES 0 NO
<br />
<br />10a, MARITAL STATUS ATTIME OF DEATH 0 Marriod 0 Novar Married
<br />
<br />o Married, but seperaled lllWldowed 0 Dlvorcod 0 Unknown
<br />
<br />11_ FATHER'S-NAME (Flrsl,
<br />(Unknown)
<br />
<br />Middle,
<br />
<br />Lasl,
<br />
<br />SUUiX)
<br />
<br />12_ MOTHER'S-NAME (FIrSI, Middle,
<br />Mildred (NMI) Neulan
<br />
<br />Maiden Surname)
<br />
<br />(Yeo, no, or unk,)
<br />
<br />13_ EVER IN U.S. ARMED FORCES? Glva dates ot service It yes_ 14a.INFORMANT-NAME
<br />No Sandy Sebesta
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Daughter
<br />
<br />o Burial
<br />
<br />o Donation
<br />
<br />16a. EMBALMER-SIGNATURE
<br />(Not Embalmed)
<br />
<br />16d, CEMETERY, CR~MATDRY DR OTHER LOCATION
<br />
<br />- r ;6b_ LICENSE NO,
<br />
<br />
<br />CITY /TOWN
<br />
<br />18c, DATE (Mo., Day, Yr.)
<br />August 19, 2005
<br />
<br />STATE
<br />
<br />15, METHOD OF DISPDSITION
<br />
<br />SlllCre,nalion 0 Enlombment
<br />o Removal 0 Olher (Specity)
<br />
<br />Central Nebraska Cremation Service, Gibbon, Nebras~a
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, Cily or Town, Stato)
<br />Kleine Funeral Home, 3213 W North Front St., Grand
<br />
<br />IMMEDIATE CAUSE,
<br />
<br />onset 10 death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dlSMse or condition resulting
<br />in death)
<br />
<br />~) SMALL CELL CA LUNG
<br />
<br />3 YEARS
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsel 10 doalh
<br />
<br />Sequentially IIs1 conditions, If
<br />any, leading to Ihe cause IIsled
<br />on line e_
<br />Enterthe UNDERLYING CAUSE
<br />(dlseese or Injury thai Inlllaled
<br />Ihe evento resulting In doalh)
<br />LAST
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENC~ OF:
<br />
<br />I
<br />I
<br />He
<br />I onset to death
<br />I
<br />I
<br />I
<br />I onsello deelh
<br />I
<br />I
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />o AccldenlO Pending Investigation
<br />o Suicide 0 Could not ba delermlned
<br />
<br />21b, IFTRANSPORTATION INJURY
<br />Q Driver/Operator
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Olher (Specify)
<br />
<br />19_ WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />iJ YES ~
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />DYES ;rrfc;
<br />
<br />PART II, OTHER SIGNIFICANT CONDlTIDNS-Condilions contributing to the death bul not resulllng In the underlying cause given In PART 1_
<br />
<br />o Not pregnant within past year
<br />o Pregnant at lime of death
<br />o Nol pregnent, bul pregnanl wllhln 42 days of dealh
<br />o N~t pragnant, bUI pregnant 43 days 10 1 year belore dealh
<br />o Unknown il pregnant within Ihe past year
<br />
<br />21a, MA~R OF DEATH
<br />-.\::(Nelural 0 Homicide
<br />
<br />21d_ WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH'
<br />DYES 0 NO
<br />
<br />DYES iJ NO
<br />
<br />
<br />220, PLACE OF INJURY-AI home, tarm, slreet, lactory, Of lice building, conslruclion site, elc, (Speclty)
<br />
<br />22a, DATE OF INJURY (Mo_, Day, Yr,)
<br />
<br />22d_INJURY ATWORK?
<br />
<br />221, LOCATION OF iNJURY - STREET & NUMB~R, APT NO,
<br />
<br />ClTYffOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a, DAT~ DF DEATH (Mo_, Day, Yr.)
<br />August J~,}005
<br />23b_ DATE SIGNED (Mo., Day, Yr.)
<br />August 19, 2005
<br />
<br />24a, DATE SIGNED (Mo_, Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c, TIME OF DEATH
<br />17:30 Iln
<br />
<br />.,~ ~
<br />.og;a::
<br />~"'~
<br />!f-:t~
<br />E_lIJtZ
<br />Sffizo
<br />,8z=>
<br />~~8
<br />o~
<br />u"
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo_, Day, Yr_) 24d_ TIME PRONOUNCED DEAD
<br />m
<br />
<br />249. On the basIs of examination and/or Investlgatlon, in my opinion death occurred at
<br />Iho time, data and place and due 10 Ihe ceuse(s) slated, (Signalure and Titlo ) l'
<br />
<br />28b, WAS CONSENT GRANTED?
<br />NOI Appllceble II 26a is NO 0 YES ~
<br />
<br />NE 68803
<br />
<br />28a_ REGISTRAR'S SIGNATURE
<br />
<br />26b, DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />AUG 2 3 2005
<br />
|