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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 />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~,'"h , /~;J~~,' ,,/f", ,
<br />
<br />DATE OF ISSUANCE 2 0 0 81 0 2 61 J-'v-.~/tt~~~ ~'pPFR
<br />
<br />NOV 2 7 2007 ASS/S1'A'N.r'P~T~1!EGJsl'~AIJ
<br />LINCOLN, NEBRASKA HEALl'Ij /fNg HUMAN ~S;,
<br />" ;:':' " J:"';,'rJ;i;J~.~ . 'It;
<br />
<br />, ; ~SEAC\':'~":1"t;
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINl\~, EcANQ.sUPPO ': lj'r;; 4 2', 0
<br />CERTIFICATE OF DEATH ...."...;"" ,.' ',' ;-" .:;i> ~
<br />
<br />2.SEX.J....~ili j;, ,'(C(c ""l)f(Mo..Day.Yr,)
<br />Male.f '. Movf.imDer 12, 2007
<br />~ ...' , " \ill ',.,
<br />
<br />Middle. Lest,
<br />Ruzicka
<br />
<br />Suffix)
<br />
<br />-
<br />
<br />
<br />1. DECEDENT'S.NAME (Flr.l,
<br />Emil AJ.vin
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sargent, Nebraska
<br />
<br />Se. AGE. Lest Birthday Sb, UNDER 1 YEAR
<br />(Yr.,) MOS. DAYS
<br />86
<br />
<br />Sc. UNDER 1 OM
<br />HOURS MINS,
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />March 12, 1921
<br />
<br />7, SOCiAL SECURITY NUMBER
<br />120-07-4412
<br />
<br />Se. PLACE OF DEATH
<br />J:iQ.SEilAJ.: CI Inpatient Q1l:JEB:!lit Nursing Home/LTC 0 Hos~lce Facilily
<br />"'.IIiI".~':.:ir~,.....~"-',~"..,.,'~."_J""""".~'_"- ,.-... ",. -~,...l':::-'::",.."....-.............."",..,...."",,"_,
<br />
<br />o ER/Oulpellenl 0 Decedent's Home
<br />
<br />8b, 'FACILITY-NAME (if not IMtllutlon, 'give street and' nU;';ber)
<br />
<br />Grand Island Veterans Home
<br />
<br />DOC)'.
<br />
<br />CI Other (Specify)
<br />
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />
<br />ga, RESIDENCE,STATE
<br />Nebraaka
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />gl. ZIP CODE
<br />68803
<br />
<br />gg, INSIDE CITY LIMITS
<br />il YES 0 NO
<br />
<br />9d, STREET AND NUMBER
<br />2300 W Capital Ave.
<br />
<br />lOa, MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married lOb, NAME OF SPOUSE (Flr.l, Middle, Lest, Suffix) If wife, give maiden neme.
<br />
<br />o Married, buteeparated liitWldowed CI Divorced 0 Unknown
<br />
<br />I 1, FATHER'S.NAME (Fire\, Middle,
<br />Frank (NMI) Ruzicka
<br />
<br />Lest,
<br />
<br />SuffiX)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Mary (NMI) Polan
<br />
<br />Middle,
<br />
<br />Maiden SUrname)
<br />
<br />13, EVER IN U.S. ARMED FORCES? Give dates oleervice if ye.,
<br />(Yes, no, orunk,) 09/16/1942-01/16/1946
<br />
<br />lS. METHOD OF OISPOSITION
<br />
<br />,BI. Burial 0 Donation
<br />
<br />o Cremation 0 Entombment
<br />
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Son
<br />
<br />, 6b. LICENSE NO.
<br />1254
<br />
<br />CITY /TOWN
<br />
<br />16C, DATE (Mo" Day, Yr, )
<br />November 16, 2007
<br />
<br />STATE
<br />
<br />o Removal o Other (Specily) Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS ISlreet, City or Town, State)
<br />Kleine Funeral Home, 3213 W North Front
<br />
<br />IMMEOIATE CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Finel
<br />dl..... oreondlllon reaulllng
<br />in daath)
<br />
<br />(a) ~ \ ~(.li J (t~!.d. \0. r '\- \) <t (' \c. ~~
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />
<br />). II..\. r
<br />
<br />onset to dealh
<br />
<br />Sequentially list cDndltlon$,lf
<br />any, IlIdlng to tha Cluaanated
<br />onlinBa.
<br />Enlarlhe UNDERLYING CAUSE
<br />(disease or Injury that Inlllatad
<br />the evenlS /Hulling in death)
<br />I.ASf
<br />
<br />(b) D'-\:>,p'r-, l>I.I\ \Q..,.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />}\ '1 .['
<br />
<br />onset to death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 deeth
<br />
<br />(d)
<br />
<br />PART II, OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the desth but not resulllng In Ihe underlying cauee given in PART I.
<br />
<br />~I::rf~ (~""\W",,,-\ b.~ ~<....~ I C~re\?ro,,~w \W- ~(. ~ ~,,-\-
<br />
<br />o AccidentO Pending Investigation
<br />CI Suicide 0 Could not be determined
<br />
<br />21b, IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o pa..engar
<br />
<br />o Pedestrien
<br />
<br />o Other (SpeCify)
<br />
<br />19, WAS MEOICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~O
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />DYES l>>"No
<br />
<br />20. IF FEMALE;
<br />o Not pregnant within past year
<br />o Pregnant at time ot death
<br />o NOI pregnant, but pregnant within 42 days of death
<br />o Not pregnanl, but pregnant 43 days to 1 year belore dealh
<br />o Unknown if pregnant within the past year
<br />
<br />21a, !-1~ER OF DEATH
<br />.. Naturai 0 Homicide
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />CI YES 0 NO
<br />
<br />DYES 0 NO
<br />
<br />
<br />22a, DATE OF INJURY (Mo" Day, Yr,)
<br />
<br />22b. TIME OF INJURY 22c, PLACE OF INJURY.At home, larm, etreet, fectory, office building, construction site, etc. (Specify)
<br />m
<br />
<br />22d. INJURY AT WORK?
<br />
<br />22f, LOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />CITYITOWN
<br />
<br />$WE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF OEATH (Mo" Day, Yr,)
<br />I' ~ Id .=t::. "-},
<br />23b, DATE SIGNEO (Mo" Day, Yr.)
<br />\\~ - 0,
<br />
<br />24a. OATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23d. To the besl 01 my knowledge, deeth occurred at the time, dete and piace
<br />and due 10 the cause(s) etated. (Signature end Tille) '"
<br />
<br />
<br />:s:~~
<br />h:~
<br />D.D.iI(~
<br />~~~iiS
<br />.8z;i!
<br />~lfc:s
<br />815
<br />
<br />m
<br />
<br />24c. PRONOUNCEO DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />IheUme, dale and place and duelo the ceuse(s) steted. (Slgnelure end Tille)'"
<br />
<br />2S, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />o YES~O CI PROBABLY 0 UNKNOWN DYES I2f NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICI""N OR COUNTY ATTORNEY) (Type or Prlnl)
<br />Jennifer King, M.D., 2300 W Ca ital Ave., Grand
<br />
<br />28e. REGISTRAR'S SIGNATURE
<br />
<br />2Sb. WAS CONSENT GRANTED?
<br />
<br />Not Applicable if 26a I. NO 0 YES 0 NO
<br />
<br />Island NE 68803
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />NO VI 1 2007
<br />
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