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<br />.. <br /> <br />8/2/2004 <br />LINCOLN, 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 RECOFm ON FILE WITH <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TIS!JJJS~~i!!-1jICH IS <br /> <br />:::;::~:::::~TORY FOR VITAL RECORDS. . . . . __~O~~- {~:-:7jj'!~ <br />200610798 ~ANLE!<"_ <br />'. A~BrAtiF#!-A 'l~ iftpiSJ!RjR <br />HEAL TH AN"!f~MAti$ER'V1eE! &,,!,,~ <br /> <br />STATE OF NEBRASKA- DEPARTMENT OF HEALlH AND HUMAN S$,~ ~ANCEA@ ~~RT <br /> <br />VITAL STATISTICS '_ <br />CERTIFICATE OF DEATH <br /> <br />4. CITY AND srATE OF BIRTH I/fnotin U.S,A.. namB country) <br /> <br />UNDER ,. YEAR <br />5b. MOS. I DAYS <br />I <br /> <br /> <br />-04 08278 <br /> <br />L DECEDENT - NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />IMonth. Day. Year) <br /> <br />Vir <br /> <br /> <br />Male <br />UNDER 1 DAY <br />50. HOURS' MINS <br /> <br />June 27, 2004 <br />6. DATE OF BIRTH (MOnth. Day. Ye.r! <br /> <br />Page, Nebraska <br /> <br />7. SOCIAL SECURTIY NUMBER <br /> <br />Jul 26, 1924 <br /> <br />S1. Francis Medical Center <br /> <br />~~~TAL.; Q Inpatient <br />o ER Qutpalienl <br />D DOA <br /> <br />~~~; <br /> <br />0 NurSing Home <br />D Residence <br />D other (Spec/tvl <br /> <br />507-24-5488 <br /> <br />Bb. FACILliY - Name (If flat lf1stlttltion, give street and livmber) <br /> <br />14a. uSUAL OCCUPATION (Giv~ kina 01 work fJenfJ during most <br />of working lif8, 8V8fI if fstirOO) <br /> <br />lOb. <br /> <br /> <br />Hall <br /> <br />. ~o. CITY. TOWN OR LOCATION OF DeATH <br /> <br />lid. INS'C;'H,'TY LIMn,,; "0. COUNTY OF DEATH <br /> <br />Grand Island <br /> <br />Nebraska <br /> <br /> <br />9d. STREET AND NUMBER (Including Zip Coos! <br /> <br />ge INSIDE CITY LIMITS <br /> <br />g.. RESIDENCE - STATE <br /> <br />Hall <br /> <br />68801 Yes Q No 0 <br /> <br />1:3. NAME OF SPOUSE (II wifi;!. give mai(!en name) <br /> <br />10. RACE - le.g., White. Slack. American Indian, <br />.tc.IISpeo,1y1 <br /> <br />White <br /> <br />11, ANCESTRY le.g. Italian, Mexican, German, etc\ <br />ISpecdYI <br /> <br />German/French <br /> <br />Bonnie L. Ruzicka <br /> <br />LAST <br /> <br />Automotive <br />17. MOTHER <br /> <br />College ('.40f5~1 <br /> <br />Auto Technician <br /> <br />16. FATHER - NAME <br /> <br />FIRST <br /> <br />MIODlE <br /> <br /> <br />MIDDLE <br /> <br />MAIDEN SURNAME <br /> <br />Charles Dallegge <br /> <br />, 6. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />(Yes. na. C}r' unk.) (If yes, give war and dates 01 servicesl <br />NO <br /> <br />Clara Delay <br /> <br />Bonnie L. Dallegge <br /> <br />19b. INFORMANT <br /> <br />MAILING ADDRESS <br /> <br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIPI <br /> <br />1015 W. Anna 81. Grand Island, Nebraska 68801 <br /> <br />20. EMBAlMER - SIGNATURE & LICENSE NO. <br /> <br />22a. <br /> <br /> <br />2,.. METHOO OF DISPOSITION 21 b. DATE <br /> <br />210. CEMETERY OR CREMATORY NAME <br /> <br />~ <br /> <br /># 1325 <br /> <br />[K] Burial 0 Removi;l1 <br /> <br />Jun 30, 2004 <br />2'd. CEMETERY OR CREMATORY LOCATION <br /> <br />M1. Pleasant Cemetery <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />Apfel-Butler-Geddes Funeral Home <br /> <br />o Cremation D Donalion <br /> <br />Cairo, NE <br /> <br />22b. FUNERAL HOME ADDRESS <br /> <br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br /> <br />23. IMMEDIATE CAuSE <br />PART <br />I <br /> <br />1123 W. 2nd St. Grand Island, Nebraska 68801 <br />IE~TER ONLY ONE CAUSE PER LINE FOR lal. Ibl. AND lell <br /> <br />/' <br /> <br />Interval between onsel aM death <br /> <br />lal <br />--CtJ'ETO, OR AS A CO:-JSl::Ol;C:NCI1 :IF <br /> <br />C-e:-~_~ <br /> <br /> <br />,---") <br />~~.- <br /> <br />?- <br /> <br />IntCirv;:!1 <br /> <br /> <br />Ibl <br />DUE TO. OR AS A CONSEOuENCE OF: <br /> <br />Intervi:ll between onsel and deatl1 <br /> <br />lei <br />~AAT OTHE:Fl SIGNIi=ICANT CONDITIONS - Conditions contributing to the death but not related <br /> <br />II <br /> <br />Homicide <br /> <br />InvestIgation <br /> <br />2"e. INJURY AT WORK <br />Yes 0 No D <br /> <br />M <br />261, 6ffi~;Su~~I~~.J~~.Y it~!lY'. farm. streel.lactory <br /> <br /> <br />26a. <br /> <br />2flb. DATE OF INJURY (M". O.y. Yr.( 26e. HOUR OF INJURY <br /> <br />o <br />o <br />o <br /> <br />Accident 0 Uncletermined <br />Suicide 0 Pending <br /> <br />2"g. LOCATION <br /> <br />STREET OR R.F.D, NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />27'. DATE OF DEATH (Mo,O.Y. Yr.) <br /> <br />260. DATE SIGNED (Mo.. Ooy. Yr.) <br /> <br />28b. TIME OF DEATH <br /> <br />~" <br />~~ <br />p~ <br />u ~~ <br />.8~ <br />~,!! <br /> <br />June 27, 2004 <br /> <br />I~u <br />~~>- <br />~~~ <br />g~" <br />:=~8 <br />u B <br /> <br />M <br /> <br />29. <br /> <br /> <br />26e. PRONOUNCED OEAD IMQ.. Day. Yr.) <br /> <br />28d. PRONOUNCED DEAD (Houri <br /> <br />M <br /> <br />M <br /> <br />~ee. On lhe basis of examination and10r investigation. in my opinion death aC:;Curred at <br />the time, date and place and clUB to lhl!!l causel$l stated. <br /> <br />30.b WAS CONSENT GRANTED? <br />DYES <br /> <br />1]::NO <br /> <br />31. <br /> <br />{Type or Pn"ntJ <br /> <br />Gordon J. Hrnicek M.D. <br /> <br />ster <br /> <br />Grand Island, Nebraska. 68803 <br /> <br />32a. REGISTRAR <br /> <br />32b. DATE FILEjUrSiARO(M200'4'! <br />