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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND ,HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASQ41DEPAYN1 iNT, OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR _Lak�4QR tlS:,
<br />DATE OF ISSUANCE f
<br />AUG 2 200 �SW$T I• COOPER
<br />2 0 0 8 0 9 9125w1$TA�T REGISrf2A` l�
<br />C1EPo1 RTM 1y DQ 4 H ,qND
<br />LINCOLN, NEBRASKA 14L194'N SERVICES.,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN.S�jiVl6'FS
<br />CERTIFICATF CIF nFATH
<br />YV IV
<br />1. DECEDENTS-NAME (Pint, Middle, Last, Suffix)
<br />2 SEX '�
<br />pATE,06 D H (Mat ay,Yc)..
<br />-ALT I -
<br />Donald Andy Zichek
<br />r
<br />Male ` `'
<br />All usU,2©d8
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />0a. AQE -Last Birthday
<br />6b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />S. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Tree)
<br />M08.
<br />DAYS
<br />HOURS
<br />MINE.
<br />Lincoln, Nebraska
<br />88
<br />October 8, 1919
<br />7. SOCLAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />Ir
<br />562 -36 -8286
<br />HQSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility
<br />0
<br />~
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<br />❑ ER/Outpafianl ® Decadent's Home
<br />Bb, FACILITY -NAME (If not Institution, give street and number)
<br />2741 Brentwood Blvd
<br />❑ DOA ❑Dlher(Spechy)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Bd. COUNTY OF DEATH
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<br />Grand Island 68801
<br />Hall
<br />Z
<br />9a. RESIDENCE -STATE
<br />96. COUNTY
<br />Be. CITY OR TOWN
<br />LL
<br />i
<br />Nebraska
<br />Hall
<br />Grand Island
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<br />9d. STREET AND NUMBER
<br />So. APT. NO.
<br />9f. ZIP CODE
<br />9g. INSIDE GITY LIMITS
<br />!�
<br />2741 Brentwood Blvd
<br />68801
<br />® Yee [I No
<br />41
<br />10a, MARITAL STATUS AT TIME OF DEATH M Married ❑ Never Marrlpd
<br />10b. NAM@ OF SPOUSE (First, Middle, Last, Suffix) If wife, give Malden name.
<br />Married, but separated tJ Widowed ❑ Divorced ❑ Unknown
<br />w
<br />Delores Peters
<br />a
<br />E
<br />11- FATHER'S -NAME (Flat, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />O
<br />Ed Zichek
<br />Agnes Varga
<br />to
<br />m
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service If Yea.
<br />144, INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />q
<br />F-
<br />(Yea, No, or Unk.) Yes 7 17 42-91301 46
<br />1 Delores Zichek
<br />S Ouse
<br />16. METHOD OF DISPOSITION
<br />10a. EMBALMER - SIGNATURE
<br />106. LICENSE NO.
<br />10c. DATE (Moen Day, Yr,)
<br />Burial ❑Donallon
<br />Not Embalmed
<br />Au east 5, 20DB
<br />®cnmallon �Entamhmenl
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Removal ❑Other(apecify)
<br />Central Nebraska Cremation Service Gibbon Nebraska
<br />178. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town. Slate)
<br />17b. ZIP Cade
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />68801
<br />CAUSE OF DEATH See Instructions and exam lea
<br />1e- PART). Enter the chain of even.. di- e, Inludem, or eompllnaDO4a- Ohm directly cawed the Ceeth- 00 NOT enwr remind even. much A. eardlme offset, APPROXIMATE INTERVAL
<br />respinnory amel, or vmnlneuier n&dllallen wilh.ul sh.wl.g the egology, 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If neteaeory.
<br />IMMEDIATE CAUSE; I onset to death
<br />IMMEDIATE CAUSE (Final I
<br />disease ) or condition resulting 4) trauma t0
<br />In death head from fd11 )
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />I
<br />Sequandally list conditions, If b) I
<br />any, leading to the cause listed
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />I
<br />Enter the UNDERLYING CAUSE C) ( -
<br />(disease or Injury that Initialed
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST I
<br />d) l
<br />10. PART 11. OTHER SIGNIFICANT CONDITIONS- Condlllons contributing to the death but not resulting In the underlying Cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />R,'
<br />W
<br />LL
<br />20. IF FEMALE, 21a.
<br />MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />[]Net pregnant within peat year
<br />�-t
<br />LL Ural Homicide
<br />ry
<br />l.J Driver /Operator
<br />❑ YES NO
<br />W
<br />❑Pregnant at time of death Id
<br />Accident ❑ Pending Investigation
<br />❑ Passenger
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />U
<br />❑ Not pregnant, but pregnant within 42 days Of death ❑
<br />Suicide C] Could not be determined
<br />❑ Pedeelrlan
<br />J]
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />Other (Specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />❑Unknown If pregnant within the past year
<br />m
<br />d
<br />OZia.
<br />DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />221, PLACE OF INJURY -At home, farm, street, factory, office building. Construction site, ale. (Specify)
<br />m
<br />August 3 2008
<br />Tjnkr wn
<br />Home.
<br />m
<br />v
<br />22d. INJURY AT WORK?
<br />22e. DESCRIBE HOW INJURY OCCURRED �w
<br />~
<br />OYES [I NO
<br />I
<br />Fell in the bathroom
<br />221. LOCATION OF INJURY - STREET 6 NUMBER, APT. NO, CITYrTOWN STATE ZIP CODE
<br />2741 Srentwood.:Blvd Grand Island NE 68801
<br />23a. DATE Or DEATH (Mo., Day, Yr.)
<br />z 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />v
<br />OQ
<br />$'Y7, August 6 2008 between
<br />4 23b. DATE SIGNED (Moe, Day, Yr.) 23c. TIME OF DEATH
<br />y
<br />PI 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />,z m
<br />0 0
<br />}
<br />�E Na i August 3, 2008 10:50
<br />o m
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<br />a c 23d. To the beat of my knowledge, death occurred al the time, date and lace
<br />$ W 24e. On the basis Of examination nveellgadon, In my opinion death occurred
<br />and due to the cause(&) stated. (Signature and Title)
<br />C at the time, dale and due to the couse(e) Staled. (Signature and Title)
<br />U Deputy Hall
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />20a. HAS ORGAN OR TISSUE DONATION, BEEN CONSIDERED?
<br />20b. WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ PROBABLY UNKNOWN
<br />❑ YES ® NO
<br />Not Applicable If 26a Is NO [] YES []NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Aaron Kunz,._Deputy Hail County Attorney. 231 S. Loggst-S-tr9at. Grand TAInndi. NE-6.8801
<br />28a. REGISTRAR'S SIGNATURE
<br />20b.
<br />DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />AuG l s zoos
<br />YV IV
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