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<br />STATE OF 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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITALSTATlSI/l;5-51!G'1JmJ, WHICH IS
<br />
<br />::;:::'.:~::E=RY FOR Y~AL RECORDS. m?lf!XER
<br />MAY 2 9 2007 200709 .t 8 3 ~'A'SSIStifJ\tF--SiA-re REGi$AR
<br />LINCOLN, NEBRASKA ~ JjE~HHANCiHUttAAN ~Jl!CES
<br />
<br />~
<br />
<br />_ . _7".'._ _ __
<br />__ _ __'r'm..._ ,._
<br />..- - -- ----- ".
<br />
<br />
<br />STATE OF"N",E,BRASKA - DEPARTMENT OF H, E,ALTH AND HUMAN SERVICES F.,Oc~.E.@, $,', ,,~i~ 2 5 518
<br />, . __~ 'n CERTlfI<:;,ATE OF DEATH ._,=."",~=--t;Fi
<br />
<br />1. DECEDENTS.NAME (First,
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />Sa, AGE.Last Birthday
<br />(Yrs.)
<br />
<br />5b, UNDER I YEAR
<br />MOS, DAYS
<br />
<br />2,SEX
<br />
<br />Female,
<br />
<br />50, UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />]~~Y 5, 2007
<br />6, DATE OF BIRTH (Mo.. Day, Yr,)
<br />
<br />Flo:r:~q~.~_ V~r in~a
<br />4. CITY AND STATE OR TERRITORY, OR FDREIGN COUNTRY OF BIRTH
<br />
<br />Jarz
<br />
<br />Abbott
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />..,~~'p!,~ska
<br />
<br />75
<br />
<br />June 2, 1931
<br />
<br />Ba. PLACE OF DEATH
<br />
<br />.__,._._ 507-36-3891
<br />
<br />l:tQ.SEJIAl :
<br />
<br />II Inpatient
<br />
<br />QlliEa Cl Nursing HomelLTC 0 Hospice Facility
<br />
<br />give street and number)
<br />
<br />U I::R/Outpatient
<br />
<br />o Decedent's Home
<br />
<br />x~at Pla~ns Re~~onal Med~cal Center
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />o to\ (J Other (Specify)
<br />Bd, COUNTY OF DEATH
<br />
<br />Ita,
<br />9d, STREET AND NUMBI::R
<br />
<br />69101
<br />..~_n"'l9b'COU~incoln
<br />
<br />
<br />Lincoln
<br />
<br />202 Pra~rie Road
<br />lOa, MARITAL STATUS ATTIME OF DEATH Xl Married 0 Never Married
<br />
<br />9g. INSIDE CITY LIMITS
<br />~ YES 0 NO
<br />
<br />lOb, NAME OF SPOUSE (First, Middle, Last, Suttix) If wite, givs maiden name.
<br />
<br />o Married, but separated 0 Widowed Q Divorced 0 Unknown
<br />
<br />Charl~::;.Jarzynka
<br />
<br />1 1. FATHER'S.NAME (First,
<br />
<br />Middle,
<br />
<br />Lasl,
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S.NAME (First,
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />Edward
<br />
<br />H.
<br />
<br />Behrens
<br />
<br />Rosa
<br />
<br />E. Kroe e.!:._."...
<br />14b. RELATIONSHIP TO DI::CI::DI::NT
<br />
<br />Sister
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dates of service it yes, 14a,INFORMANT.NAME
<br />
<br />(Yes, no. or u~kJ __:NJL.
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />II Bu,ial 0 Donetion
<br />
<br />o Cremation Dl::ntombment
<br />
<br />Dgroth
<br />l:ti..BALMER:SIG'~
<br />
<br />~
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />
<br />16b. LICENSE NO,
<br />131. D
<br />
<br />16c. DATI:: (Mo" Day, Yr,)
<br />
<br />
<br />",Z_Q~O 7
<br />STATE
<br />
<br />CITY I TOWN
<br />
<br />iJ Removal 0 Other (Specify)
<br />
<br />For~.McPherson National Cemetery
<br />17s. FUNERAL HOME NAME AND MAILING ADDRI::SS (Street, City or Town, State)
<br />
<br />Maxwell
<br />
<br />Nebraska
<br />
<br />17b. Zip Code
<br />
<br />
<br />P.D.Box 489 North Platte, Nebraska 69 03-0489
<br />
<br />wanson Funeral Home
<br />
<br />ART l. Enter the c.ha~..diseaS8S, injuries, or compllcallons--that directly caused the death, DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest. or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add additional lines if necessary,
<br />" ..
<br />IMMI::DIATE CAUSE:
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE (Final ll--
<br />dl.....orcDndttIDn...ultlng DUE TO, OR AS A CON EQUENCE OF:
<br />tndoalh) /1 A . . /J /" ;J
<br />
<br />Soqu.ntlaltylt.tcondltIDns, II _(bl... ___L.t,1.NL1IU /-11.,{./' ~
<br />any, loading 10 the cauae nstod DUE T'O OR AS A CONSEQUI::NCE 71 . ---
<br />On line B. '
<br />Enler,he UNDERLYING CAUSE
<br />(dloa... Df Injury ,ha, Inllisted (c)
<br />the evonll resul,lng In doalh) DUE TO, OR AS A CONSEOUENCE OF:
<br />LASr
<br />
<br />
<br />onset to deafh
<br />
<br />I onsel to dea.th
<br />
<br />onset to death
<br />
<br />onset to daath
<br />
<br />(d)
<br />
<br />~AS MEDICAL EXAMINER
<br />
<br />OR CORONE CONTACTED?
<br />
<br />o YES NO
<br />
<br />lCt.JF FI::MALE:
<br />~Not pregnant wIthin past year
<br />o Pregnant allime of death
<br />o Not pregnant, but pregnant within 42 days of death
<br />o Not pregnant, but pregnant 43 days to 1 yoar before death
<br />o Unknown jf pregnant within the past year
<br />
<br />21 b, IF TRANSPORTATION INJURY ""'- WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />DYES
<br />
<br />)(NO
<br />
<br />o Suioide 0 Could not be determined
<br />
<br />o Pedestrian
<br />o Other (Specify)
<br />
<br />21d, WI::RI:: AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />FINJUAY (Mo" Day, Yr,)
<br />
<br />
<br />~,TIME Of INJUffi' 22e,-f'l"'CE OFtNJUAY.At homa, tarm, streot, tactory, otflce Dulldlng, construction slle. eto, (Spacify)
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />Cl YES 0 NO
<br />
<br />221, LOCATION OF INJURY. STREI::T & NUMBI::R, APT. NO,
<br />
<br />CITYITOWN
<br />
<br />STAll::
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />z>
<br />~~!l!
<br />i;;;~
<br />ILc::;
<br />~H~
<br />1l~5
<br />~a:(J
<br />80
<br />
<br />m
<br />
<br />24C, PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the basis 01 examination and/or investigation. in my opinion death occurred at
<br />the time, date and place and due 10 the oaus.(s) stated, (Signature and Title) "
<br />
<br />AS ORGAN OR TISSUI:: DONATiON BEEN CONSIDERED? ,WAS CONSENT GRANTED?
<br />
<br />o YES ~NO W PROBABLY 0 UNKNOWN (J YES M NO Not Applloable it 26e Is~O 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER(PHYSiCIAN, CORONER'S PHYSICIAN OR COUNTy'ATIORNEY) (Type or Print)
<br />
<br />1150 Nebraska 69101
<br />
<br />J.
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />MAY 18 2007
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