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<br />STATE OF NEBRASKA
<br />
<br />~
<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. k........... ~ .................... ....... '.... .......,:,$.....;. r~......".. ..... "~"""""" ...... .A.. t'i(;' d by WFL.A
<br />
<br />JV7':: Tf,ltA"NLEY'S.' 'COOPER ','
<br />FEB 1 2 2008 20080939 6 A'~~/S:r~f.{i'S14,t~ RE.qls;f~~fl.it=EB 21 LUG8
<br />LINCOLN, NEBRASKA Hl~~ft.1:'~f/~'t~~~,S1jfl~/:f{~k".. '-'
<br />
<br />:: 2' {''t. ;\\ f',j.;,Y~j~",
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S~Ri1ieE:VFINANqE,AN9,SU. ~P, ".:0..' '.!'~(2' .'0' '8" 9 3
<br />CERTIFICATE OF DEATJ;I"--' " .i.' ". ..,;:.\ " 'l(),~" ..' . ",'
<br />~.. SEf) },I,in.": '.:1; .ri~ij'.(l;F, IiE~fli(Mo" Day, Yr.)
<br />.' ;~i.'" : .~}!'\,~~~ 23, 2008
<br />
<br />Middle,
<br />Eugene
<br />
<br />La...
<br />Chalupa
<br />
<br />Sulli.)
<br />
<br />
<br />1. DECEDENT'S.NAME (Flrsl,
<br />Donald
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />~a. AGE-Lasl BIr1hday Gb. UNDER 1 YEAR
<br />(Yra.) MOS. DAYS
<br />55
<br />
<br />
<br />,:'il.' 'DATE 0 'BIRTH (1.10.. D.y, Yr.)
<br />
<br />sargent, Nebraska
<br />
<br />November 6, 1952
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-72-7735
<br />
<br />Ba. PLACE OF DEATH
<br />J::lQjfJJAJ.,: I:l Inp.lle"1
<br />
<br />QDjfB: I:l Nursing liornelLTC I:l Hooplo. F..lll1y
<br />
<br />Bb. FACILITY. NAME (II "01 In.lllullon. glye atreel end numb.r)
<br />
<br />o ERioulpali.nl
<br />
<br />IK Decode"I'. Hom.
<br />
<br />4006 Palace Dr.
<br />
<br />1:1001
<br />
<br />o Olnor (Specify)
<br />
<br />Bc. CITY OR TOWN OF DEATH (lncludo Zip Codo)
<br />Grand Island, 68803
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />9.. RESIDENCE.STATE
<br />Nebraska
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68803
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />)( YES 0 NO
<br />
<br />9<1. STREET AND NUMBER
<br />4006 Palace Dr.
<br />
<br />100. MARITAL STATUS ATTIME OF DEATH J1(M.rriod I:l N.yOJ Merriod lOb. NAME OF SPOUSE (FirS!, Middl., LeSI. Sulll.) II wile, give m.lden name.
<br />
<br />o M.rrled, bul ,epar.l.d 0 Wldow.d 0 Diyoro.d 0 Unknown
<br />
<br />Janet Smolik
<br />
<br />11. FATHER'S.NAME (Flrel,
<br />Ernest
<br />
<br />Mlddlo,
<br />Joseph
<br />
<br />L..I,
<br />Chalupa
<br />
<br />Sui II.)
<br />
<br />12,MOTHER'S.NAlIIE (Fir.t,
<br />Lydia
<br />
<br />Mlddlo,
<br />
<br />M.lden Surname)
<br />Pesek
<br />
<br />13. EYER IN U.S. ARMED FORCES? Glye dal.. DI.OJvlcell y... 14..INFORMANT.NAME
<br />(vo.,no,orunk.) No Janet Chalupa
<br />16. METIiOD OF DISPOSITION c'...."I6li:~......- MER.SIGNATURE /-7
<br />Jl(Surlal ODDn.Uon c......... . .. . . ~
<br />o Cremalio" 0 EnlDmbmonl lSd.. CEM TERY. CREMATORY OR OTHER LOCATION
<br />o Removal OOlhor(Spoclly) Grand Island City Cemetery
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />
<br />CITY I TOWN
<br />
<br />16c, DATE (Mo.. D.y, Yr. )
<br />Jan 26, 2008
<br />
<br />STATE
<br />
<br />lSb, LICENSE NO.
<br />1092
<br />
<br />Grand Island
<br />
<br />NE
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreot, City orTown, Stala)
<br />Curran E\ln,;u;'a~ Cb.apoi>~ 3005 SQuth Locust
<br />
<br />18. PART I. Enter 1he ~.a.J...mDa~-dIGease&, Injuries, or compllcatlone--lhal directly caused the dtl8lh. DO NOT enler terminal events such as cardlDc arresl,
<br />nHipiratory arrasl, Or ",entriclJlar Iibrlllallon without showing the eUology. DO NOT ABBREVIATE. Enler only Gnu cause on a line. Add pddUlonalllnes II necessary.
<br />
<br />IMMEDIATE CAUSE (Final
<br />d1..... or condition resulU"g
<br />In doo1h)
<br />
<br />Sequenlle/ly 11.1 condlllona,lI (b)
<br />.ny, Ie.dlng 10lhe causell.led DUE TO, OR AS A CONSEQUENCE OF:
<br />on IIno a.
<br />Entorthe UNDERLYING CAUSE
<br />(dl.e..e.r Injury th.llnlUatod (c)
<br />~vonta ,.oulllng I" doath) . DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />IMMEDIATE C~E'
<br />(a) Lo\cV<....
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />c c;' "~ C"'---.c
<br />
<br />on.ello dealll
<br />\.-
<br />2.'. 1VS
<br />
<br />ona.t to daath
<br />
<br />on.ollo d..th
<br />
<br />onssl to dBalh
<br />
<br />(d)
<br />
<br />lB. PART II. OTHER SIGNIFICANT CONDITIONS.Condlllon. contributing 10 Ih. de.th but nol reau/llng I" th. underlyi"g causa glyon In PART I.
<br />C C c ,~::.....( ') ,,~-b\,,-< ~b ~ ,; 'iI.>.~"","
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES IK NO
<br />
<br />Cl Nol pregn.nt within pa.1 year
<br />1:1 Pregnanl olllrn. D' daalh
<br />I:l NOI pr.gnenl, bul pregn.nt wllhln 42 dayo ., de.lh
<br />o NOI pragnant, bUI prBgn.nl43 days 10 1 yaar belDro deelh
<br />o Un~nown II pragnantWltnln Iha pa.1 ye.r
<br />
<br />210. MANNER OF DEATH
<br />)(Nolur.1 Cl Homlcld.
<br />
<br />21 b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />a Drlvf;lr/Oplifalor
<br />
<br />Cl AccldantCl Pending Iny.,lIgallon
<br />o Sulcldo Q Could nol bo dolermi"ed
<br />
<br />Q P....ng.r
<br />o Podo.t;lan
<br />o Other (Specily)
<br />
<br />DYES DlNO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF OEATH?
<br />DYES Q NO
<br />
<br />DYES 0 NO
<br />
<br />
<br />2~a. DATE OF INJURY (Mo" Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.AI nom., larm, 'Iroot. tOOlory, olllco building, construcUDn sito. olc. (Spocl'y)
<br />m
<br />
<br />22d.lNJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER. APT NO.
<br />
<br />CrTYlTOWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEATH IMo" Day. Yr.)
<br />\ ,." "1...:1,.. ",l..<:)o'6,
<br />
<br />~3b. DATE SIGNED (1010" Day. Yr.)
<br />I ~. -/.- ''';' , -CCJ(:t"
<br />
<br />24a. DATE SIGNED IMo.. Day. Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23C. TIME OF DEATH !~
<br />L' " ~L C) m
<br />
<br />1>-
<br />E ~
<br />I 5~
<br />8~~~
<br />~~~
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAD IMD., D.y, Yr.)
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To Ihe be,1 01 my ~nowledge, de.lh occurrad allhollme, d.le .nd plac.
<br />'""j)d duelO Ih. caU"(SQlal.d. slgn.~'e and Tillo) "
<br />
<br />OJ/>-...:Je ----. ~ (v-J)
<br />
<br />25. DlDTOBACCO USE CONTRISUTETOTliE DEATH?
<br />
<br />24.. On th. besi. 01 examination andlor inve.llg.lion.ln my opinion daalh occurr.d al
<br />Iha time, dale .nd plac. and duelo Ihe CBUS.(') alated. (Signa lure and Tille)"
<br />
<br />
<br />2Ba. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />DYES Q(NO 0 PROBASLY 1:1 UNKNOWN 0 YES NO Not Appllcablo il 26a ia NO Cl YES )( NO
<br />27. NAME, TITLE AND ADDRESS Of CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Prlnl)
<br />Dona1d G. Wirth M. D. 2116 W. Faid1ey Ave. *400, Grand Is1and, HZ 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
<br />
<br />FEB
<br />
<br />4 2008
<br />
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