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<br />~: ~.I
<br />
<br />STATE OF NEBRASKA
<br />
<br />
<br />\
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF ~1i~Q Htif1Aft{5'ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE Nm~ !JEPAJifM,t:IlI! OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITO~~.'Ji~"p.L:f!21f~",.'" ,'i
<br />
<br />DATE OF ISSUANCE ".'~ "~
<br />:: ~TA~'(r&. c;PQPcR : ~ \ .!
<br />~~SSI3"4f1JptAtf., P.E~r:FFAR'
<br />';DEPARTMEN7f- Q1f HEAt.1J'j AND
<br />. 'uL/:JMltN SER.rrI1~$. :' ~" ,..'
<br />" ~ '.~'v.~ I ~... ~J-.... C,; .....J ,
<br />, ',' ','''el:l'' c,:--.' 'j,'"
<br />'" \ (......." -, .o,,,..,,,14,:.~~ ,'''\ -..,J
<br />~.. J l . . . .. I . f:::'I: ~J ~:~\.fJ ~I.i
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES' FiN),~~~i~b'ku~~J: ,:'~-
<br />CERTIFICATE OF DEATH ' .. . ~ ","
<br />
<br />SEP 0 5 2008
<br />
<br />200808673
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />,- II.. '
<br />
<br />
<br />1. DECEDENT'S-NAME (Firsl, Middle, Lasl, Sullix)
<br />Geor e Francis Jank
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE.Last BirthdAy 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />
<br />
<br />2. SEX
<br />
<br />Male
<br />
<br />5c. UNDER 1 DAY
<br />HOURB MINS,
<br />
<br />3. DATE OF DEATH (Mo.. Day, Yr,)
<br />Au ust 25, 2008
<br />e. DATE OF BIRTH (Mo., D.y, Yr,)
<br />
<br />Chapman, Nebraska
<br />
<br />83
<br />
<br />February 27, 1925
<br />
<br />ea. PLACE OF DEATH
<br />
<br />1::tQSflIAL.:
<br />
<br />Cl InpAllent
<br />
<br />QlliEEt "'ifr'Numlng Homa/LTC Cl Hospic. Facility
<br />
<br />Cl ERlOulp.ti.nl
<br />
<br />Cl Dacadanl's Home
<br />
<br />Countryhoyse Residence
<br />
<br />CllXll\
<br />
<br />II Olner(Spacify) ARR' t 1. i vi n
<br />Dd. COUNTY OF DEATH
<br />Hall
<br />
<br />ec. CITY OR TOWN OF DEATH (Includ. Zip Coda)
<br />
<br />Grand Island
<br />ga. RESIDENCE-STATE
<br />~._Nebrllska__",-,~_
<br />" STRftfMIDM.MlIIR
<br />421 W. 16th
<br />
<br />68803
<br />9b. COUNTY
<br />
<br />HalL".
<br />
<br />
<br />-~.-..-....~_.,
<br />
<br />gf.ilP CODE
<br />68801
<br />
<br />gg. INSIDE CITY L1MIlS
<br />
<br />XI YES 0 NO
<br />
<br />10.. MARITAL STATUS AT TIME OF DEATH ~Marrlad Cl Never Married lOb. NAME OF SPOUSE (Firsl. Middl., L.sl, Sulllx) II wile, glva mald.n n.mo,
<br />
<br />o M.rri.d, bul s.paralad 0 Wldowad ODivorc.d Cl Un~nown Ida Mae Vinecore
<br />
<br />11. FATHER'S.NAME (Flr.t,
<br />Frank
<br />
<br />Middle,
<br />J.
<br />
<br />La.t,
<br />Janky
<br />
<br />Sufi Ix)
<br />
<br />'2. MOTHER'S-NAME (Firsl,
<br />Frances
<br />
<br />Middle,
<br />
<br />M.id.n Surnam.)
<br />Nabity
<br />
<br />lob, RELATIONSHIP TO DEC.EDENT
<br />Wife
<br />
<br />13. EVER IN U.S, ARMED FORCES? Glva date. of .ervice if yas. 14a.INFORMANT-NAME
<br />(Yae, no, Or un~.) No Ida J anky
<br />15. METHOD OF DISPOSITION
<br />
<br />o Cr.mation Cl Enlombmant
<br />
<br />lad.
<br />
<br />
<br />lab. LICENSE NO,
<br />/;2.1(0
<br />
<br />I ec. DATE (Mo:, Day, Yr, )
<br />August 29. 2008
<br />
<br />iI BuriAl
<br />
<br />Cl Oonation
<br />
<br />CITY I TOWN
<br />
<br />STATE
<br />
<br />Cl Ramoval 0 Other (Specily)
<br />
<br />Grand Island Cemetery,
<br />
<br />Grand Island.
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS
<br />
<br />18. PART l. Enler (he chain 01 evenlsudlseae.es, InJuries, Or cOmpliC8.lions..lhat dIrectly caused the death. DO NOT enler termInal events such as cardiac arrasl,
<br />r.spiralory arra.l, or ventriculAr fibrilla liOn withoul showing tha allolO9y, DO NOT ABBREVIATE. Enla' only one CAu.. on .Iin.. Add additional linea II nec....ry.
<br />IMMEDIATE CAUSE:
<br />
<br />on.at to d..th
<br />
<br />IMMI;OIATE CAU9E (Final
<br />dl_ orcondl1lon ...ulUng
<br />fndelUl>
<br />
<br />(a) \)th\W 71ft
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />S';lAt..J
<br />
<br />on"1 to de'lh
<br />
<br />Soqu""u.lly lIal condition., II
<br />.ny, \eodlng to 111. cauoellltad
<br />on IIn...
<br />Enllr Ihe UNDERLYING CAUSE
<br />(dl..... Or InJuoy lhellnttlated
<br />the evenllraulllng In doolh)
<br />LASr
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on.ello d.alh
<br />
<br />(c)
<br />OUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I on.ello dealh
<br />
<br />(d)
<br />
<br />18. PART II:. OTHER SIGNIFICANT CONDITIONS:C:ondlllo,n,~ :onl'lbutl~gto Ih. d..lh bul n,ol r.sulllng I~ the und.,lriOll CaU50 [iya!l.lllJ'.aBTt_ _ _ '
<br />
<br />Cl AccldenlCl P.ndlng Inv.sligalion
<br />
<br />21 b.IFTRANSPORTATION INJURY
<br />o Driv.r/Op.rator
<br />
<br />o P....ng.r
<br />
<br />Cl p.de.trlan
<br />
<br />o Olher (Speclly)
<br />
<br />19. Wft,S MEDJCAL EXAMINEIl __
<br />OR CORONER CONTACTED?
<br />
<br />Cl YES NO
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />(I H~ Ie..
<br />
<br />OI.J-r7/UA r Tf V I L..AMJ (,
<br />
<br />21.. MANNER OF DEATH
<br />J<!"Ne,urel 0 Homicid.
<br />
<br />/Jrf c.A-J r
<br />
<br />20. IF FEMALE:
<br />
<br />l:l NOI prsgn9.nt wilhin pasl year
<br />o PregnAnt Allim. ot death
<br />Cl Not pregnent, bul pr.gnant wilhin 42 day. 01 death
<br />o NOI pr.gn.nl. bUI pregnant 43 day. 10 1 ya., belore d..lh
<br />Cl Un~nown il p,"gnant wllhin the p.st y..r
<br />
<br />o YES ~O
<br />
<br />Cl Sulclda Cl Could nol b. d.t.rmined
<br />
<br />21 d. WERE AUTOPSY FINDINGS A V AILABLETO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES Cl NO
<br />
<br />Cl YES Cl NO
<br />
<br />
<br />22a. DATE OF INJURY (Mo., Oay, Yr.)
<br />
<br />22b. TIME OF INJURY 220. PLACE OF INJURY-AI nom., f.rm, stre.l, f.Clory, olllca building, conatruclion sil., etc. (Specify)
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT, NO,
<br />
<br />CrTYnowN
<br />
<br />ST,QE
<br />
<br />ZIP CODE
<br />
<br />23A. DATE OF OEATH (Mo., Day, Yr.)
<br />5' -0 g
<br />
<br />23c, TIME OF DEATH
<br />f)',OO? m
<br />
<br />~~i
<br />IU
<br />CLG. iI( ~
<br />H~iS
<br />1le5:>
<br />,!!a:8
<br />811
<br />
<br />26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF OEATH
<br />
<br />m
<br />
<br />24C. PRONOUNCEO DEAO (Mo., Day, Yr.) 24d. TIME PRONOUNCED OEAD
<br />m
<br />
<br />248. On the basis of examinatlol'lsnd/or Investigation, In my opinion dBBlh occurred at
<br />Ihe lime, date and placa and due to the c'U$e(o) SI.led. (Signalu," end Tille) ,.
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />pG';Ea 0 NO 0 PROBABLY 0 UNKNOWN 0 YES NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />
<br />NOI Applicable it 26.1. NO 0 YES 00'N0
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />
<br />SEP 3 2008
<br />
<br />Z)
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