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<br />-'"
<br />
<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, VITAL STATISTICS SECTION, WHICH IS
<br />
<br />:::;::~~:::::~TORY FOR VITAL RECORDS. ,~.M '. .Jy~/N
<br />JV"""""~iJT"N(.ifidj.- ~OOPER
<br />OCT 0 2 ZOO? ASsISTANt~fAre}H;Gis.rllAR
<br />LINCOLN, NEBRASKA 2 0 0 8 0 7 8 4 6 HEALTtI A"ND HUIrANS/#iVICBS
<br />, ""."'...,: \~'~:I,(~ ..
<br />"'I ..:,~':*~'1.~;"\, I+~
<br />
<br />~
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FTNAt.lCe ANOSUPPORT ,.'"
<br />CERTIFICATE OF DEATH ',:,.' .'
<br />
<br />'""
<br />
<br />
<br />1. DECEDENTS.NAME (First,
<br />William
<br />
<br />MiddlS,
<br />F.
<br />
<br />Lsst,
<br />Noziska
<br />
<br />Suffix)
<br />Sr.
<br />
<br />2. SEX' '. .. , , . '3', DATB'bF riEATH (Mo" Day, Yr.)
<br />Male September 24, 2007
<br />
<br />
<br />Atkinson, Nebraska
<br />
<br />77
<br />
<br />
<br />6, DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Laot Birthday
<br />(Y...)
<br />
<br />September 1,1930
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-32-3144
<br />
<br />Sa. PLACE OF DEATH
<br />~: .Inpatiem
<br />
<br />QIl:lE8: 0 Nursing HomlliLTC 0 Hospice Focilily
<br />
<br />llb."FACILtTY'NAME (II not in.l1Iullolf,1!f.. olr.at and numban
<br />
<br />Saint Francis Medical Center
<br />
<br />OOCll
<br />
<br />o Other (Speclly)
<br />
<br />I
<br />"1
<br />
<br />.."~.-.-
<br />
<br />,'-.---'- 0 EAIOulpatlent
<br />
<br />o Decedenj's Home
<br />
<br />Bc. CITY OR TOWN OF DEATH (Include Zip COde)
<br />Grand Island, 68803
<br />
<br />6d. COUNTY OF DEATH
<br />Hall
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />9f. ZIP CODE
<br />68803
<br />
<br />Bg.INSIDE CITY LIMITS
<br />. yes ::J NO
<br />
<br />9d. STREET AND NUMBER
<br />4257 New York AV
<br />
<br />, Oe. MARITAL STATUS ATTIME OF DEATH .Merried 0 Never Merrled
<br />
<br />lOb. NAME OF SPOUSE (Firat, Middl., Lasl, Sultlxlll wife, glv. m.ld.n n.m..
<br />Ruth A. v'NOzicka
<br />
<br />11. FATHER'S.NAME (Flrsl,
<br />Frank
<br />
<br />Middle.
<br />
<br />L..l, sulllx)
<br />Noziska
<br />
<br />12. MOTHER'S.NAME (Fir.l,
<br />Josephine
<br />
<br />Middle,
<br />
<br />"~." ....." I
<br />v" Ziska l
<br />
<br />o Married, but.eparat.d 0 Widowed ODlvorc.d 0 Unknown
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glrlal.s Og!l'2ViC.lf y.s. 14a.INFORMANT-NAME
<br />lYe., no, Drunk.) Yes = 12; t954 I Ruth A. Noziska
<br />15. METHODOFOISPOSITION'6~...EM 'MER'SI9.NATUR. E /;; . 11ab.LICENSENO.
<br />DlBurlal OOonalron . ." (.l.//'lI L:../..:01I'2...J _.-1_~~ 92 ___
<br />o Cr.matlon I:l Enlombmenl 1 6d. CEMETERY, CREMATORY or ~HER LOCATION CITY I TOWN
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c. DATE (Mo" Day, Yr.)
<br />Sep 27, 2007
<br />
<br />STATE
<br />
<br />OR.moval o Otner(Sp.cily) Westlawn Memorial Park CemetA,ry, Grand Island, Nebraska
<br />
<br />
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS IStr..1. City or Town, Stale)
<br />Curran Funeral Chapel 3005 South Locust Street, Grand Island, N.Ii:
<br />
<br />PART I. Enl.r In. oilllin.Q!mllla..dis....., injuria., or complication."lnat directly caused tn. d.ath. DO NOT .nt.r t.rminal...nl. .uoha. cardiac arr..I,
<br />r..piralory arres1. or ventricular librill.tlon without showing th. .tlology. DO NOT ABBREVIATE. Enl.r only on. cau.e on oline. Add additional lines If n.c....ry.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />on.ello d.aln
<br />
<br />(s)
<br />
<br />Afl'OX I G bQ~rl
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Sequ.ntloity liot conditions, r.
<br />.ny, leading to the ceu..IIsted
<br />on line..
<br />Enlwthe UNDEftLYING CAUSE
<br />(dl..... 0' Injury Ih.t Initl.ted
<br />the evt,", resulting In deeth)
<br />I.ASJ'
<br />
<br />(b)
<br />
<br />A '7>1-h m a
<br />
<br />P'\J1) r
<br />
<br />0-. fhA c f.<
<br />
<br />
<br />;j
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />
<br />:1
<br />
<br />(cl
<br />
<br />. DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..IIO d'.lh
<br />
<br />(d)
<br />
<br />16. PART II. OTHER SIGNIFICANT CONDITIONS,Condlllon. contribuling 10 th. d..th bUI not r..ulting in the underlying cau.e given In PART I.
<br />
<br />o AccldentO Pending Inv.ollgallon
<br />o Suicld. 0 Could nol be del.rmined
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o D,lv.rlOp...to,
<br />
<br />o P....nger
<br />
<br />o PudBstrian
<br />
<br />o Oln.r (Specily)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES JI: NO
<br />
<br />21C. WAS AN AUTOPSY PERFORMEO?
<br />
<br />20. IF FEMALE:
<br />o NOI pr.gnant within p..1 ye.r
<br />o P,.gn.ntat 11m. 01 d..th
<br />o Not pregnant, but pregnant within 42 days of death
<br />o Nol pregnanl, but p,.gnant 43 day. IDly... before d..lh
<br />o Unknown if pregnan1 within thB past yoar
<br />
<br />21a.MANNEROFDEATH
<br />KNalu,.1 0 Homlcld.
<br />
<br />DYES .NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22l1..OATE OFlNJURY (MO., O.y, Yr.} '"'226.T1ME OJ: IIMiR't'. '22C:'POItt'OF INjURv.Aih'om., farm, .lr..I, i~CIC;y,o/Ii<:';'building, con.lr~~ti; sit., .t~.(SP.cilY) ..
<br />m
<br />
<br />DYES 0 NO
<br />
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CffY/fQWN
<br />
<br />STArE
<br />
<br />ZIP CODE
<br />
<br />245. DATE SIGNED (Mo., D.y, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />23d. To Ihe be.' 01 my knowl.dg., d.alh occurred .1 the lim., d.'. and place
<br />and dualo In. cau.e(.) .I.t.d. (Slgnatur. and Till.) "
<br />
<br />...~~
<br />"'Yo::
<br />Ig!o
<br />i5.il:S::;
<br />E~.tZ
<br />llffizO
<br />llz;i!
<br />~~o
<br />815
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />240. On tn. ba.l. 01 examin.lion end/or Inve.ligalion, in my opinion daath occurr.d at
<br />Ine timo, dale and plaC. .nd due to 1M c.u.o(.) atat.d. (Slgnatura and TltI.I"
<br />
<br />260. HAS ORGAN OR TISSUE DONATION aEEN CONSIDERED?
<br />
<br />DYES ~ NO 0 PROBABLY 0 UNKNOWN 0 YE~__._. :II: N? .
<br />2? NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSiCIAN, CORONER'S PHYSiCIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />Jennifer Brown M.D. 729 N. Custer AV, Grand Island, NE 68803
<br />
<br />26b. WAS CONSENT GRANTED?
<br />No. Applicable It 26. is NO 0 YES . NO
<br />
<br />26a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />26b. DATE FILED aY REGISTRAR (Mo., Day, Yr.)
<br />
<br />SEP 28 2007
<br />
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