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<br />~
<br />
<br />STATE OF NEBRASKA
<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 STA"!liiTICfjS~rfrtgN, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _~~~~~
<br />
<br />DATE OF ISSUANCE tlPf<-~7JiA~::;o$;:!oOPE~
<br />
<br />2 0 0 6 0 5 3 4 5 .. A$SIsT4f.i1fSTATJE ilEGiSTRAR
<br />LINCOLN, NEBRASKA .. HEALTH AND HUM/V'ISBRVICES
<br />
<br />-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINA_NC.EAND,Sf)pPORT --. 5
<br />Amended December 22.1__2005 CERTIFICATE OF DEATH .. ~....... . - - . ,
<br />
<br />
<br />1. DECEDENT'S-NAME (FlrSI,
<br />Frank
<br />
<br />Middle,
<br />Ceral
<br />
<br />Last.
<br />Havlish
<br />
<br />SUffiX)
<br />
<br />2. SEi(._,-'-:c--;c-",.:',-_ ...:i!o-'OATE OF DEATH (Mo., Day, Yr.)
<br />. Male __ ~oyember 23, 2005
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE-Last Birlhday
<br />(Y".)
<br />
<br />88
<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 />Lake Forest, Illinois
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />476-18-5058
<br />
<br />November 10, 1917
<br />
<br />8a. PLACE OF DEATH
<br />I:Ill.M'JIAl.; 0 Inpallenl
<br />
<br />illl:tEB: CXNurslng Home/LTC U Hospice Facillly
<br />
<br />ab: FACILITY.NAME (If not inatilutlon, give alreet end number)
<br />
<br />o ER/Oulpaliant
<br />
<br />o Deceden!', Home
<br />
<br />Center
<br />
<br />OIXll.
<br />
<br />U Olher (Speclly)
<br />
<br />68869
<br />
<br />ad. COUNTY OF DEATH
<br />Buffalo
<br />
<br />Nebraska
<br />
<br />9b. COUNTY
<br />Bl:iffale Hall
<br />
<br />
<br />Grand Island
<br />.~,." ."----'.'---...'-.-.--.. .... --,~,_.,---
<br />91. ZIP CODE 68802 9g.INSIDE CITY LIMITS
<br />:lO YES 0 NO
<br />
<br />9d. STREET AND NUMBER
<br />1617 N. Eddy
<br />
<br />-jO';:MARiTAL'STATUS ATTiME OF DEATH-Xl M;;~r;~d 0 Never Married 10b. NAME OF SPOUSE (Flrot, Middle, Laol, Sulflx) If wlte, give maiden name.
<br />
<br />o Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Esther Anna Ohlmann
<br />
<br />I I. FATHER'S.NAME (First,
<br />Frank
<br />
<br />Middle,
<br />
<br />Last! Sulfix)
<br />
<br />12. MOTHER'S-NAME (Flrsl,
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />Havlish
<br />
<br />Jose hine
<br />
<br />Dworak
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of sorvloe If yes. 14a.INFORMANT-NAME
<br />-.i"':.2.~~~~)1/16/42 .1/10/44 Ye Esther Havlish
<br />
<br />IS ;::r~a~ OF D1~~:~::I:~ 16a.EMBALME~~ ~___
<br />
<br />U Cremallon U Entomllmenl 16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />Wife
<br />
<br />16b. LICENSE NO.
<br />
<br />2 YO
<br />
<br />CITY /TOWN
<br />
<br />16c. DATE (Mo" Day, Yr. )
<br />
<br />November 28, 2005
<br />
<br />STATE
<br />
<br />o Ramoval 0 Olher (Spoclfy)
<br />_______________Zion_J:.~t~.€c'.ran Church CelIl~~~_~__
<br />17a.. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, Clly or Town, StOle)
<br />
<br />Shelton
<br />
<br />PART I. Enter the chain of eVBnts..diseasesj injuriesl or cornpllcaUons--that directly caused the death. DO NOT enter terminal events such as cardiac arrast,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT" ABBREVIATE, Enter only one cause on a line. Add addillonallines il necessary.
<br />
<br />IMMEDIATE CAUSE,
<br />
<br />on,ello dealh
<br />
<br />IMMEDIATE CAUSE (Final
<br />dlM8se or condition resulting
<br />In death)
<br />
<br />~ /5. ~B . P n ~!:~:")l1.0 0.I~_,_.
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />S (Yo. Wt! 4.:5
<br />
<br />I on.ello dealh
<br />
<br />Sequentially list conditlonsl if
<br />eny,leading to the oause 1I0ted
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that Inltleted
<br />the Bvents resulting In death)
<br />lASI"
<br />
<br />(b) COP D
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Llea...rs
<br />
<br />onsel to dealh
<br />
<br />(c) It d IJ aJ' G-cd
<br />
<br />CZ-:] e.
<br />
<br />onsello death
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF.
<br />
<br />(d)
<br />
<br />18 PART II OTHER SIGNIFICAN.T CONDITIONS;Condltlono oontrlbullng 10 the dealh bUI nol re."ulll"9ln)ile underl~lng cauoe given In PART I . 19. WAS MEDICAL EXAMINER
<br />OSJ-eOptJf"OS I 5 Wd1\ reUf\.f- pe Iv 1(::" '-I~t2J::-.+-'-Lre, '3~Il~ral.i OR CORONER CONTACTED?
<br />
<br />deq.t.'1ua..h'-v<., ~oln-+_ d is<t2- C:-I__t;!lf\.!it..p/.Jsin:J 5.P..t2MU/l:h_$ __u___n_ 0 YES Jl.NO
<br />20. IF FEMALE. 21a~NNER OF DEAm !lb.IFT;;;;--{pQRTATION INJURY 2tc. WAS AN AUTOPSY PERFORMED?
<br />o Not pregnanl within paol yesr )ll..Natural 0 Homicide 0 Drlver/Operelor >.LNO
<br />o Passenger 0 YES \.lI,.N
<br />o AccidentO Pending InvBstlgation
<br />o Pedeslrian
<br />
<br />o Nof pregnanl, bul pregnanl within 42 days of dealh
<br />o Not pregnant, but pregnant 43 dayo to 1 year before dealh
<br />o Unknown If pregnanl within the paol year
<br />
<br />o Suicide 0 Could not be datermlned
<br />
<br />21d WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />o Other (Specify)
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />DYES
<br />
<br />o NO
<br />
<br />22a. DATE OF INJURY (Mo.. Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, alreel, leclory, office building, conslrucllon slta, atc. (Specily)
<br />
<br />m
<br />
<br />nd INJURY AT WORK? [ 22~-DESC-RIBE HOWlijjij-RY-OCCURRED
<br />o YES 0 NO
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITY/TOWN
<br />
<br />STJIJE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />~~~
<br />_a:
<br />H~
<br />a.~ 4!:C ~
<br />~Hi!i
<br />llz::l
<br />00
<br />tf!a:U
<br />O~
<br />UO
<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 investigation, in my opinion death occurred at
<br />the limo, dale and place and due 10 the oouoe(s) oteled. (Slgnalure and Tille) ,.
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 's('NO
<br />
<br />Dr. Steve L.
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />DEe =-6 2005
<br />
<br />l-f1-H:'.::.A111/r\'=t (1;I;nR.1\
<br />
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