|
<br /> "7' :l 10 n n
<br /> r-, m :x: )';. r-..:>
<br /> - c::;:,. (") en.
<br /> '"" m ,~Y. <.=:>
<br /> ...... ~ c: n '"'" c:c> 0 -t
<br /> ~. ~~. ~I.. c::: l>
<br /> ~ .") z ~~\ CJ :z -t
<br /> -- '1: ~ 0 ~~. f""Tl -l (Tl
<br /> C 4 ~ rr1 C':) -<
<br />f\.) ." 0- 0
<br />S S' (J. (') " l--" <:> ....,
<br />s =t :P"l; ::c 0 00 ....,
<br />():l ~ ..,.., :z:
<br />-->. ~ ~ ~\ '=' r :r fT1
<br />S m -0 :t>- al
<br />f\.) t"- V) m ::3 .- ;JJ
<br />en ';::) 0 .- l>
<br />f\.) ~ en cn
<br /> "t J::. ;:00:;
<br /> ~~ l>
<br /> l--" ---
<br /> CJ) en
<br /> en
<br />
<br />
<br />
<br />Recorder's Memo:
<br />
<br />Lot 2, Calvary Subdivision, City of Grand Island, Hall County, Nebraska.
<br />
<br />WHEN 7HS ~CAIME'S 1HE RAllIED SEAL OF THE NEBRASKA HEALTH..1Ift ........~ .;~.:.:
<br />SYSreA( "CERTJllfES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL M&:OR/JQNF1tEtMTH
<br />THE NEBRASKA HEAL TH A'fD HUMAN SERVICES SYSTEM, VITAL STA TlS~frs;il~,'~
<br />THE LEGAL DEPOS~TORY FOR VITAL RECORDS. M. -::L.. ..-5'~"<'-'tJt~."~-~. C~..~..... '~'~.--'_~~._ ~\.
<br />
<br />DATE OF ISSUANCE 1026 2 ~df '5, .,,- " ,i:::'.,,"
<br />AUG G 2002 2 0 0 8 :~ .~.' .... -. 'Il.EJl.--.:. .=:"~ .~. gopM. -- E
<br />ASSflTJfNT:STAT.E REGIS1R'JUf]
<br />LINCOLN, NEBRASKA HEALTH AND tiiiiIA&-S~'tSTE~
<br />STATE OF NEBRASKA- DEPAR'fMENT OF HEALTH AND HL'MAN SEi:V/CES ~~MUSIJl!li'>RT
<br />VITAL STATISllCS'~-'- ,""'c'--~_~'-:',c'~' cPf2
<br />CERTIFICATE OF DEATH --"I:::; --~-=-~.'..: ;~-~7:51J "
<br />
<br />08573
<br />
<br />1 DE:CEOENT - NAME
<br />
<br />"i..
<br />
<br />,TDATf: OF DEAHl :"h);~;i~-i'J;;~" \;~~:l;~i.
<br />
<br />MiD5LE--""'.
<br />
<br />FIRS!"
<br />
<br />LAST
<br />
<br />? SEX
<br />
<br />Isabelle
<br />
<br />Alice
<br />
<br />Ruzicka
<br />
<br />_.____July 18, 2002
<br />O. DA 1e OF BIRTH IM(lnfh Dav Ye,'1r;
<br />
<br />Female
<br />UNDER 1 OA Y
<br />5c. HOVAS I MINS
<br />
<br />1929
<br />
<br />4, CITY ANO STATE OF BIRTH tlfnotinUS.A..fJiJmecountry/
<br />
<br />Sa. AGE - Lasi 8inMay
<br />{Vrsl
<br />
<br />UNDER' YEAR
<br />5". MOS. I DAYS
<br />I
<br />
<br />El ia, Nebraska
<br />7 SOCIAL SECURTIY NUM6ER
<br />
<br />October 1 'lI
<br />
<br />72
<br />
<br />8a PLACE OF DEATH
<br />HOSPrT Al n tnpahenl
<br />~ ER Outp<.lti$nt
<br />D I)OA
<br />
<br />OTHfR fl N!I'''1~1q H()r~ll'
<br />
<br />D A~sll1er'll.I~
<br />
<br />D Om!:'! l$tlL'C.h
<br />
<br />506-32-8615
<br />
<br />8b. FACILITY - Name
<br />
<br />(If nor institution, give Slreet ilnd numberj
<br />
<br />St. Francis Medical Center EIS...___
<br />So ciTY TOWN OR LOCA TlON OF DElI TH
<br />
<br />. 16. FATHER - NAME
<br />
<br />
<br />Bd. INSIDI; CITY UMITS
<br />
<br />Grand Island
<br />[ !la. t:l;~H;:ENCE." ST A T~
<br />
<br />Nebraska
<br />10. RACE. le.g" White. BlacK. America.n IMian.
<br />etc.) (Spe~ltyl
<br />White
<br />
<br /> m
<br /> 2:
<br />0 rrl
<br />'" :IJ
<br />m
<br />0 0
<br />0 :r>
<br />en
<br />CO 2
<br />~ iI
<br />c::';) c:
<br />N :s:
<br />ITI
<br />CJ) Z
<br />-f
<br />N Z
<br /> 0
<br /> ~
<br /> <,
<br />
<br />f-ej!,! INsii:ii7~(~Tl:-YI~i'Mi.is.
<br />! y~~ EJ No D
<br />_".., __.1 ...__.__._.___
<br />13 NAME OF SPOuSE:: (II wile. .QIW~ m.:lId~!n ni-lme)
<br />
<br />Emil A. Ruzicka
<br />
<br />ll1a. USUAl. OCCUPATION {(;ivekindolwof./rdon8t11JrirJ.gmosl
<br />Df working life. 6V8n if fetif80!
<br />
<br />HaneMaker
<br />FIRST MIDDLE
<br />
<br />Own H
<br />~A5T 17 MOTHER
<br />
<br />15. EDUCATION (SpeCify only hUiilhesl !;jrade c.ompleted)
<br />
<br />EI~r2tl1r SGr~d~121 CO!leg~ {j.1l ()' 7,-1
<br />MIDDLE -- MAfD!::N SURN-A~-----
<br />
<br />tius NMI
<br />16 WAS DECEASED EVER IN uS. ARMED FORCES'
<br />IYes. no. or unk.j (II yeS. give war anc;l dates at servicesl
<br />No N/A
<br />Hlb INFORMANT MAI~ING ADDRESS'
<br />
<br />Frances
<br />
<br />NMI
<br />
<br />Koziol
<br />
<br />Krason
<br />
<br />19a. INFORMANT. NAMf
<br />
<br />Emil A. Ruzicka
<br />ISTREET OR RFO'NO. CITVORTcwi'N$fA TE lIPj-"---
<br />
<br />
<br />Island Nebraska
<br />"a METHOD DF D,SPOSIIION
<br />
<br />
<br />NAME:
<br />
<br />.7
<br />
<br />~ Bunal D Remo,.,: Jul
<br />
<br />D Cr~malion D DOr"',}ll(1r"'
<br />
<br />Kleine Funeral Home
<br />
<br />Park Cemet
<br />
<br />68803
<br />
<br />Gr?l!}d Island, Nebrasls9.
<br />
<br />STATF
<br />
<br />22". CuNERAL HOME ADDRfSS
<br />
<br />(STREET OR R.F.D. NO. CITY OR TOWN. STATE. ZIP}
<br />
<br />3213 W. North Front Street, Grand Island, Nebraska
<br />
<br />n IMMBlIA TE CAUSE IENTER ONLY ONE CAuSE PER LINE mR "1 101, AND 1<11
<br />PART
<br />I
<br />
<br />hlp-r.,:;1 ~p.tween onset ,111(1 (!r~\1:1.
<br />
<br />Natural
<br />
<br />2 hours
<br />
<br />causes
<br />
<br />lal
<br />QUE TO. OR AS A CONSEOUENCE OF
<br />
<br />l~ll"r'!AI t1p.I\IIi~en on!;;!'!! .1'"1(1 <'1'''','':1'
<br />
<br />1&1
<br />
<br />TO. OR AS A CONSEOUENCE OF.
<br />
<br />..-.." -~.,--"._.
<br />In!(lr\l':,1 1,.:,jW"i"~ ".,,,,,,1 ,,,,,,;I ~jw.,:.;:~
<br />
<br />1<1
<br />PART OTHER SIGNIFICANT CONDITIONS - ConditIons I;ontributing 10 the dealh bul not felaled
<br />
<br />II
<br />
<br />
<br />PART III IF FEMALE. WAS THERE A
<br />PJ':l~GNANCV IN lH!:. pMn 3 MONTHS?
<br />
<br />..iAg.e~2.o.-541 Yes n r::?".. Yes
<br />1260. DESCRIBE HOW INJURY OCCURRED
<br />I
<br />
<br />?5 WAS CASE REFERR[() ! 0 Ml::()\(;Al
<br />::X:A~INFR OR CQRONEf\'J
<br />
<br />Ye,.0 __~ufl_
<br />
<br />27a. DATE OF DEATH (MO. D~y. y,)
<br />
<br />
<br />28a. DATE SIGNED (Mo Day Y'I 12sb"IiM'~-iiF-DEATH'"''''
<br />July 23, 2002 I 1:58 am
<br />t--------------
<br />128~ rRO~JOijNCL:O DE.:AO (~'()lJrj
<br />I 1 : 58 am
<br />
<br />2tI. 2tlb. DATE OF INJURy 26c. HOUR OF INJuRy
<br />0 Al;cldent 0 Undetermined
<br />0 SUIC"'" 0 Pendinq 260. INJuRY AT WORK
<br />0 Homicide InvesllgallOr"l vesD NoD
<br />
<br />26g. LOCATION
<br />
<br />S fREET OR R.F.D. NO
<br />
<br />':-:'Ty OR TOWN
<br />
<br />r~:-~ .
<br />
<br />it.., ~"~'"m ,~ ~, '" - '"",", OC ~rn J i! ~ g - _""~'OO",
<br />
<br />
<br />~ 1 ~ 270. To Ih. I>>st of my ,no",loog. ,..,h occu'"d ., tIl. "~me 1ate and olac. and duo 10 IM.~ ~ ~ @ J u 1 y
<br />calJse(sf staled. I ~~'.: .',
<br />
<br />l$i naluf8 aM Till&) ..
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />DYES [] NO D UNKNOWN
<br />
<br />31 NAME AND ADDRESS OF CERTIFIER /PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY I ITy()8 ",Printl
<br />
<br />Jerom E Janulewicz, Hall County Atty, 117 E 1st,
<br />
<br />{Ma.. Day, Yr.i
<br />
<br />
<br />lia1l
<br />
<br />yES
<br />
<br />D NQ
<br />
<br />Grand Is land,
<br />
<br />NE
<br />
<br />32a REGISTRAR
<br />
<br />
<br />32". DATE FI~ED BY REGISTRAR iMo Day y()
<br />
<br />JUL 2 9 Z002
<br />
<br />5TA Ii-
<br />
<br />.. ~1
<br />
<br />"
<br />
<br />Co
<br />
<br />Atty
<br />
<br />68801
<br />
|