|
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDJiUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIG/~RtcbRD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA7iST/css"ECnQitWHICH IS
<br />
<br />:::;::~;:::::;TORY FOR VITAL RECORDS. '. :~~-~=j;):J:--
<br />JAN 23 2007 j.....~~~~.tER
<br />LINCOLN, NEBRASKA 2 0 0 70 4 6 8 2 ~~~~:~r:;t;;i:~~~~~~~
<br />
<br />''\
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANce AND SUPPOFp\ 6 3 4 4 5 9
<br />_____~_ CERTIFI~ATE OF ()EATH ___--.1L__
<br />
<br />
<br />1. DECEDENT'S.NAME (First.
<br />Letha
<br />
<br />Mlddla,
<br />Evelyn
<br />
<br />Lasl,
<br />Jisa
<br />
<br />Sulfix)
<br />
<br />2. SEX
<br />Female
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 23, 2006
<br />
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF alRTH
<br />
<br />5a. AGE-Lo.t airlhdoy
<br />(Yro.)
<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 />Paul, Nebraska
<br />
<br />74
<br />
<br />January 5, 1932
<br />
<br />t p. LACE OF DEATH
<br />HO.sElIA1: 0 Inp.lient
<br />--..,.. ... . -::;:-.=:;.;'-:--.:,.' -- -
<br />8b. FACILITY-NAME (If not Instllutlon; 'glve a'r.er and IlIirilburj --l
<br />Q ERlOutp.tlanl
<br />Francis Skilled Care Nursing O~
<br />
<br />-'-'-_.."-'~. ~~"~
<br />80. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island, 68803 Hall
<br />
<br />';;~:~~;E_-~__\ 9~~~i .___= I~~::~W~Sland
<br />
<br />9d. STREET AND NUMBER
<br />318 Ruby AV
<br />
<br />QIHEB:
<br />
<br />IX Nursing Home/LTC 0 Hospice Faclllly
<br />
<br />CJ Oacadent'8 Hgl\'IG
<br />
<br />o Oth.r(Speclly)__...
<br />
<br />1 Da. MARITAL-STATUS AT TIME OFDEATH IXMarrled 0 Never Merrled ]IDb NAME OF SPOUSE (Flrsl, Middle, Lesl, Suffix) II wile, give m~lden nam7-
<br />OMarrled,bulsapereted OWldowed DDlvorced OUnknown Charles John Jisa
<br />
<br />"....----~~~ --- ~~
<br />t t. FATHER'S.NAME (Flrsl, Middle, Lesl, Sulllx) 12. MOTHER'S-NAME (Firsl, Middle,
<br />Lewis J. Nabi ty Lillian C.
<br />
<br />;~~:~:~O;~~~kS)' ;~_DFORCES? Give dales ~Is~rvice IIYe~;;~:;~~;ohn Jisa lO-'==:=-=-' ~~:~=~HIPTO DECEDENT
<br />
<br />15. METHOD OF DISPOSITION. ':Z...6a;;:r~_=R-~IGNAT. U ~R. .E_ l,q/.f"'} /} .'- 16b. LICENSE NO. 160. DATE (Mc.. Day, Yr.)
<br />!Kaurial o Donation (:~~ L~./M-o-.J .. 109~ Dee 27, 2006
<br />
<br />OCramatlon 0 Enlombmanl 16d. CEMETERY, CREMATORYOR OTHER LOCATION CITY /TOWN
<br />
<br />
<br />91. ZIP CODE
<br />68803
<br />
<br />gg. INSIDE CITY LIMITS
<br />K YES 0 NO
<br />
<br />Maiden SurnE!.rne)
<br />Polansky
<br />
<br />STATE
<br />
<br />QRemovel UOlher(Specify) Westlawn Memorial Park Cemetary
<br />
<br />Grand Island. Nebraska
<br />
<br />..-"---
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (8Ireel, City or Town, Slale)
<br />Curran Funeral Chapel 3005 south LocU$t Street
<br />
<br />oneel 10 dealh
<br />
<br />IMMEDIATE CAUSE (Final
<br />dt..... 0/ condition resulting
<br />In dealh)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />,~ .'
<br />~ ._~vJe..e, _ _ . [) bs;\...-'-\'( CA'llS'v"-~
<br />
<br />DUE TO, OR AS A OONSEQUENCE OF:
<br />
<br />aWft,fto_
<br />
<br />, onaal 10 death
<br />
<br />sequenll.lly liet ccndlllono, if (b)
<br />any1leadlng to the cause listed DUE TO, OR AS A CONS'EOUENCE-6F.~--~~-
<br />onllneo. .
<br />E","rthe UNDERLYING CAUSE L' \-
<br />(di..... or Injury that Inllioled (C)~"~\-7/L ~T--O''-~ . L.-- Q\JIJ.r(' \ (-\.. v'\
<br />the eventsresulllng In death) ---:-DUE TO, OR AS ACONSEQUENCE OF:
<br />lAST
<br />
<br />: /0)
<br />...____L1IL.6'ADll/-HtJ
<br />
<br />I onsello death
<br />',-.
<br />
<br />CIA 11\ CLA...../_~... O~d~~-
<br />I
<br />I
<br />
<br />(d)
<br />
<br />-~.".~,,~,_.-
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />U YES IX NO
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contrlbullng 10 the dealh but not resulting in Ihe underlying cause given in PART I.
<br />
<br />~o. IF FEMALE: 21e. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 210. WAS AN AUTOPSY PERFORMED?
<br />i<tI KNelu I 0 Ho I Id 0 Driver/Operetor
<br />,f" Nol pregnant within pasl year ro me e 0 YES IX NO
<br />o pregnant elllme 01 dcalh 0 AccldenlO Pendiny Invastlgalion 0 pa.senger --.
<br />o Nol pregnanl, but pregnanl within 42 days cl deelh U Suicide Q Could ncl be delermlned 0 Pedesj;len 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pragnant, bul pregnanl 43 dey.lo 1 year belor. daath 0 Olher (Speclly) COMPLETE CAUSE OF DEATH?
<br />_~C:tu_~nownil.Jl[.!~~~nl_~I~~~!y~~~~~-"~-_.._- ... .m~~~__..__~_ ~.__~..:....~=-:---- _ 0 YES 0 NO
<br />22a. DATE OF INJURY (Mo.. D.y, Yr.) f2b. TIME OF INJUR~ 22C. PLACE OF INJURY.AI hom~, ferm, .lre.l, 'aclory: ollic. t;ullding, conSlrucllcn sita, etc. (Spaclfy)
<br />
<br />22d.iNJURY AT WORK? ]:-22a DESCRIBE HOW INJURY OCCURRED-' -.---.-. .
<br />o YES 0 NO
<br />---~ ~-_._,-
<br />221. lOCATION OF INJURY _ STREET & NUMBER, APT. NO. crNITOWN STJlJE ZIP CODE
<br />
<br />24e. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />Nb. TIME OF DEATH
<br />
<br />"~~,,~",.,.......~
<br />
<br />:z>-
<br />~:!!!l!
<br />~'"
<br />),.0
<br />e-~ S ~
<br />E"i:Z
<br />l:lffizO
<br />4>z::>
<br />"'00
<br />~a:.O
<br />fh
<br />
<br />m
<br />
<br />.4c. PRONOt!NCED DEAD (Mo" Day, yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis olexaminatlcn and/or Investlgallon, In my opinion dealh occurred el
<br />the time, dale and place and due 10 the oouse(s) sleled. (Slgnalure and Title).
<br />
<br />'f,5. DID TOBACCO USE CONTR"BUTETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />. 0 YES II NO 0 PROBABLY 0 UNKNOWN . ... 0 YES. M NO
<br />---i7. NAME, TITLE AND ADDRESS OF CERTIFiER (PHYSiCIAN, CORONER'S PHYSiCiAN OR COUNTY ATTORNEY)- (Type or Pri~-
<br />Rebecca J. K. Steinke M.D. 2116 W. Faid19Y AV suite 400, Grand
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />Ncl Applicable if 26e Is NO .0 YES .IX NO ...
<br />
<br />Island, NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY.fANTRA~ r'Z007
<br />
|