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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT QF HEALTyy41V~7gHL(1~1f1~41-5'~RV~ICE$, IT CERTIFIES
<br />THE BELOW Tp BE A TRUE COPY OF THE QRIC,INAL RECORD ON FILE WITH THE NEBRAS~C"A,D~'A~7'J~IEII/T`~7~ /-IEJ4,l.;TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE; WHICH IS THE LEGAL DEPOSITORY FOR V~TALW RE ~~ ~~~.;"• ' ° ;
<br />' ? ,'. ' ~
<br />DATE OF ISSUANCE ~ . ,
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<br />MAR Li g 210 ASSll51;14{VT.'~•Tq~fJf~E~IS1jRAR ~ : ,~
<br />201dd6614
<br />DEP~IR~EN7' OF a~lEAI.TH AdVp. ,:
<br />LINCOLN, NEBRASKA HUM.AN~'~R,V~E
<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AN~$UP~•r;;~~ ~ r~ j~ ,,a,
<br />CERTIFICJaTE AF nFOTN jj l.G
<br />1. DECEDENT'S-NAME (First, Middle, Last, _ Suffix) 2. SEX 3.~bIVf@;~F.,9EAThl,,SMg,; pay,YG)
<br />Jolene Lee Jelinek March 21 2010.
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGB-Last Birthday _ ___
<br />5b. UNDER 1 YEAR 5c. UNDER 1 DAY 5. DATE OF SIgTH (Mo., D@y, Yr.)
<br /> (Yrs.) MOS. PAYS HOURS MINS.
<br />Grand I81and, Nebraska 72 November 13, 1937
<br />?.SOCIAL SECURITY NUMBER Ba. PLACE pF DEATH
<br />508-40-1409 _ HOSPITAL: ~ Inpatient 9IFJEB: ^ Nur$IngHomelLTC ©Hospic@Facillty
<br />eb. FACILI7Y•NAME (If not Inatltutlon, glue street and number)
<br />Q ERlputpatlen[ U Deoedenl'a Home
<br />$t. FraS1C18 Modical Center ^ ppq ^ Other(Speclfy)
<br />8c. CITY QR TOWN OF DEATH (Include Zlp Cade) Bd. COUNTY OF DEATH --•-•----~.~__..._ _
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<br />813 Hall
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<br />Ba.RE51DENCE•STATE 9b.000NTY __~_~_~ µ~
<br />Oc.CITYORTDWN _
<br />Nebraska Hall Grand Island
<br />9d. STREETANDNUMBER ge. APT. NO Bf. ZIP CODE 9g. INSIDE CITY LIMITS
<br />1019 Ea 6~" St. 68801 ~ YES ^ No
<br />10e. MARITAL STATUS ATTIME OF DEATH ^ Mewled ^ Never Mewled 106. NAME OF SPOUSE (First, Middle, Last, 5utfix) If wife, glue maiden name.
<br />^ Monied, but separated ~ Widowed Q Divorced ^ Unknown
<br />11. FA7HER'S•NAME (First, Middle, Last, $utfix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />Duke (NbII) Dural]d Thelma NMI Rosa
<br />13. EVER IN U.&. ARMED FORCES? Glve dates of service If yea. 14@.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(vea, no, @r unk.) (HO ) Srian Jel,inek
<br />15. METHpD OF p18POSITION 18a. EMBALMER•51GNgTURE 166. LICENSE N0. 16c. DATE (Mo., Day, Yr. )
<br />^8urial ^Donation NOt EmbalmeCl
<br />~..__ - w ...._... _----- Maa~ah 22 2010
<br />~Crematlon ^ Entombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br />^ Removal ^ Other (Specify)
<br />Central Nebraska Cremation Service, Gibbon, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City drTdwn, State) 17b. Zlp Code
<br />Aleine Funeral Homa, 3213 N North Front St., Grand Island NE 6$$03
<br />18. PART I. Enter the gJ]gjn of eventa••diaeeaes, injuries, or complicationa••lhat directly caused the death, DO NOT enter terminal events such ae cardiac arreal, APPROXIMATE INTERVAL
<br />- ^' -~i@epir@9ery arrest or v@ntrldeler BMlhatton'withom @nowing Iha etiology. UO NDT ABBREVIATE. knteronry one ca~ay do a line. Add atldititlnal6nea it netleasery. I
<br />IMMEOIA7E CAUSE: I onset to death
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<br />IMMFAIATBCAUSE(FlIW (@)
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<br />dlaeeseorwndkbrt rsautting DUE T0, OR AS A CONS ENCE OF: I onset to death
<br />In death) ~ f~/./,~.
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<br />eny,leadingteth@causellsted DUE TO, ORASACON5EOUENCEOF: I onset to death
<br />on Ilse a.
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<br />EntertheONDERLYINGCAUSE
<br />(disease or InJury that Inltl@ted (c) I
<br />tlpeWMeroaukinglndaetll) ~pUE T0, OR AS A CONSEQUENCE pR
<br />I onset todeeth
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<br />18. P T IL OTHER SIGNIFICANT CONDITIONS-Cdndltldns cdntrl6uting td the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
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<br />l ~ OR CORONER~C,O/tyTACTED7
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<br />~ ^ YES yY NO
<br />20. IF EMALE~ 21 @. MANNER OF ATH 216. IF7RANSPORTATIONINJURY 21c. WA3 AN AUTOPSY PERFORMED?
<br />
<br />of pregnant within past year U Natural ^Hdmlclde ^Driver/Operator
<br />C.I YES
<br />Q Pregnant at time of death ^ Accldent^ Pending Inv@stlgetlon ~ Passenger
<br />^ Not pregnant, but pregnant within 42 days of death
<br />^ Suicide ~ Could not be determined ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />© Not pregnant, but pregnant 43 days to 1 year belore death ^ Other (Speclly) COMPLETE CAUSE OF DEATW7
<br />^ Unknown if pregnant within the past year ^ YES ^ NO
<br />22a, pgTE pF INJURY (MO., Day, Vr.) 22b. TIME OF INJURY
<br />m 22c. PLACE OFINJURY-At home, farm, streef,tactory, office building, construction alts, etc. (Speclly)
<br />22d.INJURYA7WORK7 22e.DESCRIBEHOWINJURY000URRED
<br />^ YES.. ^ NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT. N0. CfTY/fOWN f ~ ~5TATE~~ ~_._._w_ ZIP CODE
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<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) Z } 24a. GATE SIONED (Mo., Day, Yr.) 246. TIME OF DEATH
<br />•. ~~ March 21, 2010 ~.~ _ _ m
<br />8 236. DAT IG D (Mc., D@y, Yr) 23aTIME OF DEATH ~ ~ 24c, PRONOUNCED DEAD (Mc., Day, Vr.) 24d.71ME PRONOUNCED pEAD
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<br />my knowledge, death occurred et the time, date end place y
<br />24e. On the 6@sle of @xeminafion andlor investigation, in my opinion death occurred at
<br />~ ~ to use(s) a tad. (Signature and Title) ~ B P5 p the time, date and place and due td the cause(s) stated. (Signature and Title) ~
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<br />ONTRIBU7ETO7HED 7 28a.HASDRGANpRTI$SUEDONATIONBEENCONSIDERED? 28b.WA5CONSENTGRANTED9
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<br />YNO ^ PR08AeLY ^ UNKNOWN ^. YE5 l.?'NO Nat Applidable if 26a is NO ^ YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,CORONER'SPHY5ICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />John A. Wagoner M.D. 800 Alpha St. Grand Island NE 66803
<br />28@.REGISTRAR'S5IGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
<br />~~ , ~. MAR $.4 2010
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<br />HHS-81 11 /03 (55081)
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