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<br />
<br />STATE OF NEBRASKA
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<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 -RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL siAi/STICS.sECf.lQN WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . 0:;'-.'."-_ -,:'. '".~: ~~'lJ"/.
<br />
<br />
<br />~~~;,:;~~~ ..20060505 6 f~~!~~~
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<br />STATEOFNEBRASKA-DEPAR1~~'?I~~~~;~N~~U~~~~~VICESF1NM~CEANoS:UPP()fjT DLl 0 6 21
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<br />1. DECOOENT'S.NAME (First, Middle, La'l, -.--~,-.," ._-~ _ms':;;;-:; 2. SE~"----" 3. DATE OF DEATH (Mo" Day, Y,-) ---I
<br />Bonnie L. Cliffords Female September 14, 2005
<br />
<br />
<br />69
<br />
<br />
<br />e. DATE OF BIRTH (Mo" Dey, Yr.)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE.LaslBlrthday
<br />(Yrs.)
<br />
<br />Brainard, Nebraska
<br />
<br />February 11,1936
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-42-2454
<br />
<br />Ba. PLACE OF DEATH
<br />IJQSEJIAJ.: 0 Inpalienl
<br />
<br />8b. FACILITY-NAME (If nol inslitullon, give slreot and number)
<br />
<br />o ER/Outpatlanl
<br />
<br />QII:IEB: 0 Nursing Homo/LTC Q Hospice Facilily
<br />...
<br />Q Decadent's Home
<br />
<br />3623 Bronco RD
<br />
<br />Q[XYI
<br />
<br />IXOlher(SPeClly)Daughter' S
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />80. CITY OR TOWN OF DEATH (Includa lip Codo)
<br />Grand Island, 68801
<br />
<br />ga. RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b. COUNTY
<br />Polk
<br />
<br />gc. CITY OR TOWN
<br />Osceola
<br />~"I9;APT.NOI~E ----p-g~ INSiDE CITYi:;MITS'
<br />I 6865:?:".._~ K YES 0 NO
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Suffix) II wile, glva maiden name.
<br />
<br />9d. STREET AND NUMBER
<br />311 Hoosier
<br />
<br />100. MARITAL STATUS AT TIME OF DEATH U Merried U Never MeTtled
<br />
<br />o Married, but separeled MWldowed 0 Dlvoroed U Un~nown
<br />
<br />t 1. FATHER'S.NAME (First, Middle, Lasl,
<br />Frank Tesinsky
<br />
<br />:~~~~~;:olr:u~~~: ~~:ORCES? Glvo da;~~-~I~~'~I:lf ~~..:::l'.~~;;MA-NT~~lf fords
<br />
<br />t5. METHOD OF DISPOSITION ~. ~~,.Ii' . ME~-.S. IGNA;URE Im-) /I. ..' ... J 1Sb.. LICENSE NO.
<br />KSurlal 0 Donellon .".":~ ~t:!(/l) ~ ~,JAc:..)_ . I ()(} ~
<br />Deramaflon 0 Enfombmanl 1Sd. CEMETERY, CREMATOR 0 OTHER LOCATION CITY /TOWN
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (First,
<br />Alice
<br />
<br />Middle, Malden Surnema)
<br />Dvorak
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />SOn
<br />
<br />, Sc. DATE (Mo., Day, Yr. )
<br />Sap 17, 2005
<br />
<br />STATE
<br />
<br />o Removal OOlher(Specify) Prague National Cemetery
<br />
<br />Prague
<br />
<br />NE
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<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS IStreal, City or Town, State)
<br />Kracl Funeral Chapel 1622 F. Street PO Box
<br />
<br />PART I. Enter the chain of 8ventsudise85aSj InJurl96, or compllcatlonsuthat directly caused the death. DO NOT enter terminal events such as cardiac arrestl
<br />ra.piratory arre.l, or venl,ioul., IIbrlllallon withoul.howlng tho otlology. DO NOT ABBREVIATE. Enter only one c.u.e On a line. Add additional line. II nece.sary.
<br />IMMWIATE CAUSE:
<br />
<br />-~~ETO;ORAbi~~~OF:~~------
<br />
<br />onset to de'lh . ... . j
<br />
<br />fY\6V\.~_
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condltlon ,esulUng
<br />Indaeth)
<br />
<br />Sequentially list conditlonsl if
<br />any, leading 10 the oau...llatod
<br />on line o.
<br />Enter thO UNDERLYING CAUSE
<br />(disease or injury that initiated
<br />tho evonto resulllng In death)
<br />LAST
<br />
<br />(b)
<br />
<br />C~\r-..
<br />
<br />CGVV'\. c...e.A---'
<br />
<br />4.~___
<br />
<br />onseltod~
<br />
<br />.~._,_...,-- ,.".,-.-
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />. DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />L
<br />onsel to death
<br />
<br />--I
<br />
<br />(d)
<br />
<br />Cl Suicido 0 could not be determined
<br />
<br />o Olher (Specify)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />Cl YES IX Nb
<br />
<br />210. WAS AN AUTOPSY PERFORMED?
<br />
<br />DYES IXNO I
<br />
<br />21d WERE AUTOPSY FINDINGS AVAILABLE Tol
<br />COMPLETE CAUSE OF DEATH? I
<br />DYES 0 NO
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<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contrlbuling to the deafh but nol "SUiting In the underlying cau.e given In PART I.
<br />
<br />20. IF FEMALE:
<br />.,;i NOI pregnant wilhin p." yeer
<br />o pregn.nl ellime of death
<br />o Not pregnent, bUI pregnanl wllhln 42 days of daalh
<br />o NOI pregnan!, bul pregnant 43 day. to 1 yeer before dealh
<br />D Unknown If pregnant within the pasl year
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<br />210. MANNER OF DEATH
<br />KNatural 0 Homicide
<br />
<br />o AccidanfO Pending Invastlgatlon
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Drlver/Operato'
<br />
<br />o Pa..enger
<br />
<br />U Pedestrian
<br />
<br />o YES 0 NO
<br />
<br />
<br />m
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />--,..,-----~.
<br />22b. TIME OF INJURY 229. PLACE OF INJURY.AI homo, fa'm, slreel, factory, oflloe building, 'conslruollon slle, etc. (Specify)
<br />
<br />22d. INJURY AT WORK?
<br />
<br />221. I.OCATION OF INJURY" STREET & NUMBER, APT. NO.
<br />
<br />crrvrroWN
<br />
<br />STI\fE
<br />
<br />ZIP CODE
<br />
<br />
<br />m
<br />
<br />I
<br />z>
<br />..LJJ
<br />E;:;~
<br />ig!o
<br />i5.it~~
<br />~~~~
<br />jlZ=>
<br />~518
<br />811
<br />
<br />24c, PRONOUNCED DEAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />m
<br />
<br />24e. On fhe basis ofexaminallon andlor Inve.ligallon, in my opinion death occurred .t
<br />fhallma, data and pla.e and due to Ihe cause(s) slalad. (Slgnalura and TltI.).
<br />
<br />25. P1DTOBACCO USE CONTRIBUTETOTHE DEATH?
<br />
<br />2Ba. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />o YES Ii( NO 0 PROBABLY 0 UNKNOWN. Cl YES M NO . Not Applicable if 26e IS NO 0 YES JI NO __
<br />-27.NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, C"Oii'ONEFiii'PHYSICIAN OR COUNTY ATTORNEY) (Type or Print; .
<br />Rebecca J. K. Steinke M.D. 2116 W. Faidley AV Suite 400, Grand Island, NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />SEP 2 3 2005
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