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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 STATISr:ICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~>j: ,/t~
<br />
<br />DATE OF ISSUANCE !9~."JrVYtI;' , ,
<br />, "ANt.n."S;"eopP/iFf
<br />OCT 0 1 2007 2 0 0 7 0 908 3 ASSIs;[/4foJl SrAtItRsDl$.riJA";
<br />LINCOLN, NEBRASKA HrAL7';' ~'ND HUIIIM:N St!#f'.pjs',
<br />/ :....: ~. ~,~ ,c.., 1~: : ,,~ III
<br />. ........ . I'll( '."\. t .~. . ,,</\ ;.;
<br />/ < . '"- ~ ~. ,...~ ~o,,~,~ .i' , ~'; t: ,~
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICes ANA~CE AND SUPf.O., . ,',.' . 3 0 2 0 4
<br />.,_ CERTIFICATE OF DEATH' "<;", ,: "...;. ,'J ___.__
<br />'{SEX .....,.. 3;~'feQF DEATH (Mo...Day, Yr.)
<br />Mate -september 10, 2007
<br />
<br />Middle.
<br />
<br />Last,
<br />Matejka
<br />
<br />SuffiX)
<br />
<br />
<br />1. DECEDENT'S-NAME (First,
<br />Franklin
<br />
<br />Dean
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Lasl BlrtMay
<br />(Yrs.)
<br />74
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />a.DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />December 17, 1932
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-38-6966
<br />
<br />8a. PLACE OF DEATH
<br />
<br />I::lQSilJAl:
<br />
<br />o Inp.tient
<br />
<br />QlliEB; 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />6b. FACILITY. NAME (II nol InOlltutlon, give streot and number)
<br />
<br />o ERfOutpatient
<br />
<br />IX' Decedentls Home
<br />
<br />4196 Nevada Ave.
<br />
<br />Oro>.
<br />
<br />o Olher (Specify)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />Grand Island 68803
<br />
<br />9~::~:=~r:E ."_,,_I-g~COU;all
<br />
<br />9d. STREET AND NUMBER
<br />4196 Nevada Ave.
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />._.~,.'~.W,'..,_
<br />lOa. MARITAL STATUS AT TIME OF DEATH lt4..Married 0 Never Married lOb. NAME OF SPOUSE (Firsl, Middle. Lasl, Suffix) If wile, give maiden name.
<br />
<br />
<br />91. ZIP CODE
<br />68803
<br />
<br />9g. INSIDE CITY LIMITS
<br />IlIl YES 0 NO
<br />
<br />o Divorced 0 Unknown Elaine L. Woi talewicz
<br />
<br />11. FATHER'S.NAME (Flrsl, Middle,
<br />Frank (NMI) Matejka
<br />
<br />Lasl,
<br />
<br />SUllix)
<br />
<br />12. MOTHER'S.NAME (Fir.', Middle,
<br />Clara (NMI) Naiberk
<br />
<br />Maidan Surname)
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give date. 01 servlcall yes.
<br />(Yes. no. or unk.) 11/25/1952-11/24/1956
<br />
<br />o Donation
<br />
<br />
<br />14a.INFORMANT.NAME
<br />Elaine L. Matejka
<br />
<br />~ Il ~ 16b LICENSE NO
<br />~__ .___ ___1t<0'f'
<br />ORY OR OTHER LOCATION CITY I TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />o Burial
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />September 21, 200
<br />
<br />JlII Cremaflon 0 Entombmanl
<br />
<br />STATE
<br />
<br />o Removal OOlher(Specily) Central Nebraska Cremation Service, Gibbon, Nebraska
<br />
<br />18, PART l. Enter the rn.amj)~DJ$..dis9as9S, Injudes, or cornplic8tions~-that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiralory arreSI. or venlrlcular fibrilla lion wilhoul showing the etiol09Y. DO NOT ABBREVIATE. Enter only one CauSa on a line. Add additional lines 'If necessary,
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Slra.', City or Town, Stale)
<br />Kleine Funeral Home, 3213 W North Front
<br />
<br />ons.tlo dealh
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in dealh)
<br />
<br />(a)
<br />
<br />eA. RDlOP--16f PtrO"i ory oVl' J ~t-
<br />
<br />8AM ~rt' It
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />ons.t 10. dealh
<br />
<br />fYI~1Q~ ilIllCi
<br />Sequontlally 1I0t condlllono,lf (b)
<br />any, loading to Ihecau..llaled DUE TO, OR-AS A CONSEQUENCE OF;
<br />on line a.
<br />
<br />Coli o.~f\
<br />
<br />~t.4nC1
<br />
<br />Prt~a1
<br />
<br />onSet to death
<br />
<br />Enlerthe UNDERLYING CAUSE
<br />(dl.ea.. or Injury lhallnlllaled (c)
<br />theeventa rea"lUng in doath) DUE TO, OR AS A CONSEQUENCE OF:
<br />LASr
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />tOPD/
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Condilions contributing 10 th. death bul not rasulling in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br />
<br />0l0f]e1rS t1'1Pt~1la'I'I1ory) IJ1 V<<U' Ufltilfl\ ID fut:iYl rn all Jrtlbflll ~ ~~:ONE~O~:ACTED?
<br />
<br />-;;;'~A~R OF DEATH ;;6 T~ANSPO[iJifI N ~URY. 21 c AS AN AUTOPSY PERFORMED?
<br />oifNalural 0 Homicide 0 Dflver/optiN>'! /+- ~
<br />
<br />o Accldan'O Pending Investlgetlon 0 Passenger
<br />o Pedestrian
<br />
<br />CJ Suicide 0 Could not be datarminad
<br />
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />20. IF FEMALE:
<br />
<br />o No' pregnant wllhin pa.1 year \. I{ A
<br />o Pregnant at time of death \'"
<br />o Not pregnant, but pregnant within 42 day. 01 daalh
<br />o Not pregnanl, bul pregnanl43 days 10 1 year belore dealh
<br />o Unknown if pregnant within the past year
<br />
<br />o Othar (Spacily)
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />DYES 0 NO
<br />
<br />cor INJ\;R',' (Mo.,~
<br />
<br />
<br />. l'homa, 'arm, straat, faclory, office building, conotruClion 0110, ale. (Specify)
<br />
<br />22d INJURY AT WORK? '1' ;"2a
<br />DYES L.lN~
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />m
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />"'~~
<br />-D~c::
<br />llg!~
<br />tifoet::i
<br />EU)[:z
<br />8ffizO
<br />.8z;l
<br />~~~
<br />86
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basis of examination and/or investigation, in my opinion dea.th occurrad at
<br />Ihe time, dete and place and due to the causa(s) stalad. (Signalure and Title)"
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONS'DERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />Not Applicebte II 26a !~!!O 0 YES 0 NO
<br />
<br />Island NE 68803
<br />28b DATE FILED B~EpTRJR 40'2007
<br />
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