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<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 ORIGINALRECOF!P ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST.!Q$,BEfrl'iON:/o__WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~.... '~~.'.::? ~'... ':.,o~ ~11.-~ _.::..'o,~
<br />
<br />DATE OF ISSUANCE n'"".'-' 'fR ~~,
<br />JOl)' L if" -f _. TANLEY S. CQDF!ER
<br />.,PI< 0 4.. [' A$$iSTAHtStAt.E11Eciji'f~R
<br />LINCOLN, NEBRASKA 2 0 0 6.0 7 8 9 6 HE,ALTH AND H1iMAN~ERVIC-ES
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<br />STATE OF NEBR.. ASKA - DEPARTMENT OF HEAL. T.H A. N.D.. HUMAN SERVICE~FINA. ~. E..A.N.. D. S. .up.' PORT.. 6.
<br />Amended Aprii 4, 2006.. CERTIFICATE_q.~_~EATH' '. __~~c,,-=- 0__ 22601
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<br />1. DECEDENT'S-NAME (First, Middle, Last, Sufllx) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />
<br />,Tam.e.s.. _._"._ Paul
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Leechburg, Pennsylvania
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<br />5a. AGE.Le.t Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. OAYS
<br />76
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<br />
<br />5c. UNDER 1 OAY
<br />-... ~"-'_..
<br />HOURS MINS.
<br />
<br />. arch 7. 2006
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />_, ..Qctgber 2
<br />
<br />1929
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<br />7. SOCIAL SECURITY NUMBER
<br />190-22-6007
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<br />8.. PLACE OF DEATH
<br />1:iQSflIAl.: 0 Inpallent
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<br />OlliE8: ~ Nursing Homo/LTC 0 Hospice Facllily
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<br />8b. FACILITY-NAME (It not institullon, give street end numbor)
<br />
<br />
<br />~ -I'
<br />Ii ll~
<br />~ ~~ Tiffany Square
<br />;~:I;~ Bc CITY OR TOWN 'OF DEATH (Inolude Zip Codo)
<br />
<br />~ \ilC Grand Isla.!!4., 68803
<br />l'~ 9a RESIDENCE.STATI:- ---~NTY------
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<br />~ .~ Nebraska ~11
<br />,... ~1! 9d. STREET AND NUMBER
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<br />_3J_J..J",_akeside Drive
<br />lOa. MARITAL STATUS ATTIME OF DEATH ~ Married U Never Married
<br />
<br />o !Xl'. OOlher(Specily)_
<br />
<br />.-~]8d~:U~~ OF DEATH
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<br />9c. CITY OR TOWN
<br />
<br />o ER/Outpatlenl
<br />
<br />o Docodent's Home
<br />
<br />68801
<br />lOb, NAME OF SPOUSE (Flrsl, Middle, Lasl, Sulllx) If wile, give melden name.
<br />
<br />
<br />91. liP CODE
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<br />gg. INSIDE CITY LIMITS
<br />~~S 0 NO
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<br />~
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<br />o Divorced 0 Unknown
<br />
<br />Joy Yost
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<br />Middle,
<br />
<br />Last,
<br />Zana
<br />
<br />Suftlx)
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<br />12. MOTHER'S.NAME (First,
<br />Frances
<br />
<br />Middle,
<br />
<br />Maidon Surname)
<br />Gavasto
<br />14b. RELATIONSHIP TO DECEDENT
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<br />13. EVER IN U.S. ARMED FORCES? Give dates 01 service II yes. 14a.INFORMANT.NAME
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<br />(Yes,no,orunk.) Yes: 6/25/1950 7/27/1953 Joy Zana
<br />
<br />15~:::~OFDI~~:~::i~~16a.~MBA~.~W ;,1. ~__
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<br />o Cremetlon 0 Entombment 16d. CEMETERY, CREMATORY ~ LOCATION
<br />
<br />CITY / TOWN
<br />
<br />..WHe.
<br />16c. DATE (Mo., Dey, Yr.)
<br />March 13, 2006
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<br />STATE
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<br />
<br />o Removal 0 Olhor (Specify)
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<br />Westlawn Memorial Park Cemetery
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<br />Grand Island,
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<br />Nebraska
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<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, Clly or Town, Slato)
<br />Apfel Funeral Home 1123 West 2nd Street
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<br />PART I. Enter the chain 01 AVAn!!1--dlseasesj Injuries! or compllcationsuthal directly caused the death. DO NOT enter lerminal events such as cardiac arrest,
<br />respiratory errest, or vontricular fibrillation wllhoul showing the etiology. DO NOT ABBREVIATE. Enter only one oeuee on ellne. Add eddltlonelllne. II necessary.
<br />
<br />IMMEDIATE CAUSE (Flnel
<br />disease or condition resulting
<br />in death)
<br />
<br />Sequentially list condition., If (b)
<br />eny, loadingtofhe causell.ted OUE TO, OR AS A CONSEQUENCE OF:
<br />on line e.
<br />Entortho UNDERLYING CAUSE
<br />(disease or Injury that IniUoted (e)
<br />theoventsre'UlllngIn deelh) DUE TO, OR AS A CONSEQUENCE OF:
<br />lAST
<br />
<br />
<br />,-n:1!~~
<br />
<br />I
<br />I
<br />
<br />I on.elto deatl1
<br />I
<br />I 2___. "_, ).'-r.(> /!__
<br />..1. . (~ -.."
<br />
<br />I onsello death
<br />I
<br />I
<br />I
<br />I onsel to death
<br />I
<br />I
<br />I
<br />
<br />onset to death
<br />
<br />(d)
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<br />18. PART II. OTHER SIGNIFICANT CONDITlONS.Condition' oontributing 10 tho doalh but nol reeulllng in the Underlying causo given in PART I.
<br />
<br />LJ Suicide 0 Could not be delerminod
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<br />21b.IFTRANSPORTATION INJURY
<br />o Driver/Operator
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<br />o Passenger
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<br />o Pedestrian
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<br />o Other (Speoify)
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<br />19. WAS MEDICAL EXAMINER
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<br />OR CORONER CONTACTED?
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<br />DY~S.,..,XNO_
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<br />2fo. WAS AN AUTOPSY PERFORMED?
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<br />20. IF FEMALE:
<br />
<br />21~ROFDEATH
<br />fiatural LJ Homlolde
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<br />o AccldenlU Pending Inve.tlgation
<br />
<br />DYES
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<br />}.!(~ 0
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<br />
<br />o Nol pregnant within past year
<br />o Pregnant at lime 01 death
<br />U NOl pregnant, but pregnant within 42 days of death
<br />o Not pregnent, but pregnanl43 days 10 t year bel ore deelh
<br />o Unknown If pregnanl wilhin Ihe past yeor
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<br />2fd. WERE AUTOPSY FINDINGS AVAilABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />U YES 0 NO
<br />
<br />DYES 0 NO
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<br />
<br />m
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<br />22a. DATE OF INJURY (Mo., Day, Yr.)
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<br />22b. TIME OF INJURY 220. PLACE OF INJURY.All1ome, tarm, slreet, faclory, office building, oonetruollon slle, eto. (Speoily)
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<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
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<br />SlAJE
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<br />liP CODE
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<br />24e. DATE SIGNED (Mo., Dey, Yr.)
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<br />24b. TIME OF DEATH
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<br />",:'l:1:i
<br />.cuz
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<br />'Q.D.C(...J
<br />!U~t~
<br />UUlZ
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<br />.coo
<br />~c:O
<br />o~
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<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />24e. On the basis of examination and/or Investigation, In my opinIon death occurred at
<br />the Umo, dato and place and due to the causels) slaled. (Slgnelure and Title) l'
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<br />25. DID TOBACCO USE CONTRIB~ ETOT 'E OEATH? 260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />o YES -NO 0 PROBABLY 0 UNKNOWN 0 YES 0 NOI_AeE!l.oable if 26a is NO 0 YES 0 NO
<br />27. NAME, TIT ANO AD[)RESS OF CERTii'iER(PHYSiCiiiN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ'.'o;p;inl)
<br />Dr. Gordon J. Hrnicek 729 North Custer Grand Island, Nebraska 68803
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<br />28e. REGISTRAR'S SIGNATURE
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<br />
<br />2Bb. DATE FilED BY REGISTRAR (Mo" D'y,Yr.)
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