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STATE OF NEBRASKA
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<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 NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT~IL R,ECDRUS.-
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<br />DATE OF ISSUANCE ~.~~,.•,~~
<br />JUL 1 O ZOO9 ~ O O O O ~ ~ ~ ~ A~ISTANT ~7"ATE REC"aXSTRAR
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<br />LINCOLN, NEBRASKA ~:hldUyACU+~~.5.` -
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<br />STATE OF NE9aASKA-- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANC~'1~SlS~~ • ` t
<br />CERTIFICATE OF DEATH ~r;. '••. `~-' '~;~~'~~;•
<br /> 1. DECEDENT'S•NAME (First, Middla, Laat, Suffix) 2. SEX ~ ~ y~QA'FEpFDEATH (May Day,Yr.)
<br /> Vera Rosalie Hanousek Female .Jul ,4;' 2009
<br /> 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGFLast Birthday fib. UNDER 1 YEAR 5c. UNDER 1 tlAY S, OATS OF BIRTH (MV., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Shelton, Nebraska $8 November 3, 1920
<br /> 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH
<br /> 505-524849 ){Q5PITAL: ^ Inpatient Q7HER: ~] Nursing Home/LTC ^HOSpiceFacllity
<br /> 86. FACILITY-NAME (If ndt Institution, glue sleet and number)
<br /> ^ ER/Outpatient ~ pecedent's Hama
<br /> Ravenna Good Samaritan Center
<br /> ^ D~ Q Other(5pecity)
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Coda) ed. COUNTY OF DEATH
<br /> Ravenna 68869 Buffalp
<br /> 9a. RESIDENCE-STATE 9b. COUNTY 9C. CITY OR TOWN ~~~
<br /> Nebraska Buffalo Ravenna
<br /> 9d. STREET ANDH0MBER 9e. qpT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 710 Grand Ave
<br />68869 ~1 YE3 ^ NO
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<br />1ga. MARITAL STATUS AT TIME OF DEATH ^ Married ^ Never Married 10b. NAME OF $PDUSE (First Middle, Ldet Suffix) It wire, give maiden name.
<br /> ^ Married, but 9apera}ed ~ Widowed ^ Divorced ^ Unknown
<br /> 11. FATHER'S•NAME (First, Middle, Last, 5uffiz) 12. MOTHER'S-NAME (First, Middle, ~ Malden Surname)
<br />~
<br /> _ Marion F.
<br />Dubbs
<br />E1ma Mosser
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<br />13. EVER IN V.S. ARMED FORCES? Glve dates of service it yes. 14e.INFORMgNT-NAME 14b. RELATIONSHIP TO pECEDENT
<br />(Yes
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<br />) No R
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<br />O er Hanousek Son
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<br />15. METHOD DF DISPOSITION i6e. EMBAL R- (GNAT E 16b. LICENSE N0. 18c. DATE (Ma., pay, Yr. )
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<br />~ la BUddl ^Donatlon z _ .7ulq g, 2007
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<br />r'~ ^Crematldn ^Enlombmenl 18d.CE TERY,CREMAq Y OTHER LOCATIDN CITY/TOWN STATE
<br /> ^Remdval ^Other (Speclly) Cameron Cemetery Wood River, Nebraska
<br />- ° 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, State) ~ 176. Zlp Coda
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<br />.. Apfel Funeral Home, 1123 West Second, Grand Island, NE 68801
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<br />',J. PART I. Enter the chain of events--diseases, in~urles, or complicatlvns-•that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> rcepiraiory arrest, or ventricular flbrillatldn without showing the etl0logy. 00 NOT ABBREVIATE. Enter only onB Cause on a tins. Add additional Ilnes II necessary. I
<br /> IMMEDI
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<br />: I onset to death
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<br />IMMEDIA7ECAU$E(Flnal (a) V Gm~Q. ~ ©~~' ,S ~nrf
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<br />~~ :~ dleepeedrermdltlvn reauging DUE T0, OR AS A CONSEQUENCE OF: i dn9et to death
<br />In death)
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<br /> Saquentlally llet dondltiana, if (p) I
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<br />any, leading td thecaueelleted -- ~ _
<br />DUE T0
<br />OR AS A CONSEQUENCE OF:
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<br />I onset to death
<br />on Ilne a.
<br /> E11Mr the UNDERLYING CAUSE
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<br />~ (dlaease yr ln)ury that initiated (c)
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<br />~, i the events raeuldng In death) - ~ ~ - _._.l.
<br />LOST DUE TD, OR AS A CONSEQUENCE OF i onset to death
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<br /> 1B. PART II. DTHER SIGNIFICANT CONDITIONS•Contlitions cantrlputing t0 the death but not resulting in the undeflying cause given In PART I. 19. WAS MEDIGAL EXAMINER
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<br />:.:~,~ ~ OR CORpNER~CON~TACTEp?
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<br />^ YES h~NO
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<br />2g.IF~FEMALE: 21 a.MANN~FROFDEATH ~ 21 b. IF TRANSPORTATION INJURY 21c.WA5ANAUTOPSYPERFpRMED?
<br />l]YFlot pregnant within pest year af0~tural ^ Homiade ~] Driver/Operator
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<br />^Pasaenger ^ YES GNU
<br />^ Pregnant at time of death ^ Accldent^ Panding Investigation
<br />' `h ~ Not pregnant, put pregnant within 42 days of death ^ Suicide ^ Could ndt be determined ^ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />4i ^ Not pregnant but pregnant 43 days td 1 year before death ^ Other (Specify) COMPLETE CAUSE OF DEATH?
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<br />^ Unknown if pregnant within the past year __,-,~ ^ YES ^ NO I `-'~~'
<br />r~ , 22e. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At hdme, farm, street factory, office building, Construction site, etc. (5pecily)
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<br />22d.INJURYATWpRK? 22e.DE5CRIBEHOWINJURY000URRED
<br /> ^ YES ^ NO
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<br />22L LOCATION DFINJURY-STREET&NUMBER, ApT.NO. Cf1Y/~OWN STATE ZIP CODE
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<br />~ 23a. DATE DEATH (Md., Day, Yr.) _ ~ 24a. DATE $IGNEtl (MO., Day, Yr.) 246,TIME OF pEATH
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<br />23b. 0ATE~=ED (MO„Day, Yr.) 230.TIME0)~;ATFI~
<br />~Y 24c. PRpNOUNCEtl DEAD (Ma., Day,Yr,) 24d.TIME PRONOUNCED DEAD
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<br />23d. To the best dl my knowledge, death occurred at the time, date end place ~ W ~ 24e. On the basis of examination and/or inve&llgatidn, in my opinion death occurred at
<br />and ue to the douse(s) slated. (Signetu and Title) / ~ ~ p the lime, date and plgde and due to the Cause(6) elated. (SignaturB and 1'ille) •
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<br /> 25. pIpT08A000
<br />CONTRIBUTETOTHE DEATH? 26a. HAS ORGAN pF TISSUE
<br />DO
<br />NATION BEEN CONSIDEREp? 26b. WAS CONSENT GRANTED?
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<br />^ YES NO ^ PROBABLY ^ UNKNOWN ~
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<br />U YES
<br />-t'NO - l
<br />Not Applicable i126a ie ND ^ YES Y"'RO
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<br />27. NAME, TITLE ANDADDRES50FCERTIFIER (PHYSICIAN,CORONER'SPHY5ICIAN OR COUNTY ATTORNEY T eorPrint)
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<br /> Kimberly Mickels M.D. 729 N. Custer Ave., Grand Island, NB 68801
<br /> 26a. REGISTRAR'S SIGNATURE ZBb. DATE FILED BY REGISTRAR (Mo.. Day, Vr.)
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<br />HHS-61 11/03 (55061)
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