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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND.HUMANSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL.fI1!i;Qjifi45i{~ITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITALSTATI~S.'SECflqfi:--Wljjet!IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . ~_..-.7-.'.~.--~'--._;.'J --.-~~.:-.. .. '---.:-.-.~-.>~.--_..c...'~~'~
<br />
<br />DATE OF ISSUANCE ~., _, t{.:~::.:::.~, ~ "-::, ~'.:
<br />JUL 1 9 2006 ~. . -- -IfNi.iiY~COOPEfi
<br />As$isii~T STATE ReGlsfr-RAn
<br />HEAL~, :~l~~{ti;~:~/,?~S
<br />
<br />2006:1064'"
<br />
<br />~
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />.
<br />"
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AN-dSOfi'e~"';.. .-
<br />CERTIFICATE OF DEATH
<br />
<br />.~~,~'.:.
<br />
<br />
<br />1. DECEDENT'S-NAME (Fltst,
<br />Leo
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />Kovarda
<br />
<br />Nile
<br />
<br />t .-9_,..2DJi_______
<br />6. DATE OF BIRTH (Mo., Day, Yr_)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5e. AGE-Le't Blrthdey
<br />(Yts.)
<br />
<br />Cff:eva,liebraska
<br />? SOCIAL SECURITY NUMBER
<br />551-20-6281
<br />
<br />94
<br />
<br />5b. UNDER 1 YEAR 5c. UNDER 1 DAY
<br />MOs.-DAYS H~U'RT;:;S:-:-
<br />
<br />tmi:er 2D 1911
<br />
<br />8e. PLACE OF DEATH
<br />J::lQ.SE1IAl.: 0 Inpatlont
<br />
<br />QIill'.8: ~ Nursing Home/LTC 0 Ho'plce Feclllty
<br />
<br />6b. FACILITY.NAME (It not institution, glvo stroot and numbor)
<br />Veterans Affairs M:dica1 Calter
<br />2201 N. ~, Grarrl Is1:n:l, NE 689)3
<br />
<br />o ER/Outpailent
<br />
<br />U Decedent'. Homo
<br />
<br />UOCl'.
<br />
<br />o Othor(Speclly)__._
<br />
<br />8e. CITY OR TOWN OF DEATH (Includo Zip Code)
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />68801
<br />
<br />9a. RESIDi::NCE-STATE
<br />
<br />9b. COUNTY
<br />
<br />
<br />
<br />YES
<br />
<br />U NO
<br />
<br />_JZ2Cl_W;>.stlJJ-de_S tr:_E!E!_t_________._..
<br />lOa. MARITAL STATUS ATTIME OF DEATH 0 Marriod 0 Novor Merrlod
<br />
<br />']
<br />tOb_ NAME OF SPOUSE (Firsl, Middla, Last, Suffix) If wile, give maiden name.
<br />
<br />o Married, but separalad XI Widowed 0 Divorced 0 Unknown
<br />
<br />11. FATHER'S.NAME (First,
<br />Charles
<br />
<br />MlddlO,
<br />NMI
<br />
<br />Last, Sulllx)
<br />Kovanda
<br />
<br />12_ MOTHER'S-NAME (Fitst.
<br />__.;ro.~e"phine
<br />
<br />Middle, Moldon Surnamo)
<br />
<br />o Donation
<br />
<br />14a. INFORMANT-NAME
<br />Mrs. Gloria Middendorf
<br />
<br />~/7E;'3
<br />
<br />CITY /TOWN
<br />
<br />NMI Luzum
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Dau hter
<br />16c. DATE (Mo" Day, Yr. )
<br />
<br />[J Cremallon [J Entombment
<br />
<br />Ma 15 2006
<br />STATE
<br />
<br />o Romoval 0 Othor (Spocify)
<br />__~_~~~_mia~_ational Cemet~l'__________~__u
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, City or Town, Stele)
<br />
<br />Farmer & Son Funeral Homes, Inc. 242 North 10th, Geneva
<br />
<br />PART I. Enter the chain of Bventsndise8sBs, inJuries, o"r compllcatlonsnthBt directly caused the death. 00 NOT enter terminal events such as cardiac luresl,
<br />respiratory arrest, or ventricular fibrillalion without showing the etiology. DO NOT ABBREVIATE. Enlef only one causa on a line. Add additIonal lines It necessary.
<br />
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />I
<br />I
<br />
<br />I on8Bllo death
<br />I
<br />I
<br />Ifpw r'IRys_____
<br />I on.otto dooth
<br />I
<br />
<br />:~ nmths
<br />
<br />I onsel to death
<br />I
<br />I
<br />
<br />IMMEDIATE CAUSE (Finol
<br />disease or condnlon re.ultlng
<br />In d.ath)
<br />
<br />(0) Aspiratim RE.nrnia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Sequentially lll!ltcondltlons, If
<br />any, leedlng to the causa listed
<br />on line 8.
<br />Enterlhe UNDERLYING CAUSE
<br />(disaa.. or InJury that Inltlat.d
<br />the events resulting In death)
<br />lASr
<br />
<br />(b).Amrex::ia 8evere M3lmtritim
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c) CVA
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />onset 10 death
<br />
<br />tioo
<br />
<br />'~.years__
<br />'9. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />CJ YES ~ NO
<br />
<br />(dwm
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions conlrlbullng to the death but nol resulting in the underlying cause given In PART I.
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAlLA6LE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />;1'LACEOP1t'l'JURY.1\l homo; !arrrr,street, tacmy;.orm:e buillling, cMstrucTRlrrslm;.ete: (Speclly) -
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />U Drlvor/Operator
<br />
<br />o Passenger
<br />
<br />o Podo.lrian
<br />
<br />o Othor (Spoclly)
<br />
<br />2'c. WAS AN AUTOPSY PERFORMED?
<br />
<br />20. IF FEMALE;
<br />o Not prognanl within past yoar
<br />U Prognant at limo of death
<br />o Nol pregnant, but pregnant wllhln 42 days of death
<br />U Not prognant but prognant43 days 10 1 yoar boloro doath
<br />o Unknown If pregnanl within the past year
<br />. ~~a. lillI ~ U1"TNJURY~-Yr;J
<br />
<br />2'a. MANNER OF DEATH
<br />o Natural t:I Homicide
<br />
<br />o YES m NO
<br />
<br />o AccldenlU Pending Investigation
<br />
<br />
<br />DYES 0 NO
<br />
<br />
<br />220. DESCRI6E HOW INJURY OCCURRED
<br />
<br />22d_INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Doy, Yr.)
<br />9 2.Cl))
<br />
<br />24e. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />230_ TIME OF DEATH
<br />6:3) m
<br />
<br />~~~
<br />~1ll15
<br />~H::;
<br />~,~~
<br />UwZ
<br /><>z;:>
<br />.000
<br />~a:t)
<br />815
<br />
<br />m
<br />
<br />~..
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d, To the beat 01 my knowledge, death occurred at the time, date and place
<br />J and duo to Iho causo(s) 'lat~slgneture end Title) ...
<br />
<br />VI yYL~-'"t J$"'l/t...../afr'\. ".Ul--v"-'_
<br />
<br />24e. On the basis of examInation and/or lrwestlgalion, in my opinion death occurred al
<br />tho tlmo, data and place and duolo tho cousa(s) steted. (Signature and Title) 'f
<br />
<br />25. DID TOBACCO USE CONTRI6UTE TO THE D
<br />
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b_ WAS CONSENT GRANTED?
<br />
<br />DYES 0 NO 0 PR06A6LY ~ UNKNOWN m YES 0 NO
<br />2? NAME, TITLE AND ADDRESS oi'-fEAi'iFIER-(PHYSICIAr{CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />
<br />~_ot ~ppll.G~bla If 26a " NO 0 YES ~ NO
<br />
<br />MAY 16 2006
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