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<br /> 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 NEBRASKA DEPARTMENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FDA! VITAL, RECO;RL)S,,
<br /> DATE OF ISSUANCE Z.,
<br /> STANLEY S. APR 13 200 ASSISTANT,STAOTE~RFGISTRAR
<br /> &PARTMENT OF HEALTH AND
<br /> LINCOLN, NEBRASKA HUMAN SERVICES
<br /> 201009473 r
<br />
<br /> STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 10 00866
<br /> CERTIFICATE OF DEATH
<br /> 1. DECEDENT'"AME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Pay, Yr.)
<br /> Hubert Joseph Horacek Male April 7, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 15a, AGE - Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY S. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Hall County, Nebraska 88 May 18, 1921
<br /> 7 SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 505-18-2740 HOSPITAL ❑ Inpatient Q 1 a ❑ Nursing Homldq(; _ ❑ Hospice Facility
<br /> :fAoGQTY44 L''(irfMllrt~ttttdfdrr, a et SW .nuinber)
<br /> r~ ❑ ERlOtdpaNem ®Daudem. Home
<br /> ~i 2703 W. Forrest St. ❑ DOA ❑ Other (Specify)
<br /> aW 6c. CITY OR TOWN OF DEATH (Include Zip Code) 6d. COUNTY OF DEATH
<br /> o Grand Island 68803 Hall
<br /> 9a. RESIDENCE-STATE
<br /> eb. COUNTY 9c. CITY OR TOWN
<br /> ? Nebraska Hall Grand Island
<br /> LL 9d. STREET AND NUMBER e. APT. NO. 9f. ZIP CODE 9g, INSIDE CITY LIMITS
<br /> 2703 W. Forrest St. 68803 ® YES ❑ NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH JZ Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) lfwife, give maiden name
<br /> _ © Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Lillian Frances Collins
<br /> 11, FATHER-S-NAME (First, Middle, Last, Suffix) 12, MOTHER'S-NAME (First, Middle, Malden Sunburns)
<br /> Anthony Horacek Emma Klinkacek
<br /> E 17. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 142. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> $ (Yee, No, or Unk.) No Lillian Frances Horacek Wife
<br /> 15. METHOD OF DISPOSITION 1ea. EMBALMERSIGNATURE 18b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br /> 12 ❑ Burial ❑ Donation Not Embalmed
<br /> April 8, 2010
<br /> ® Cremation ❑ Entombment
<br /> 180. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ❑ Removal ❑ Other (Specify)
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE DEATH (See instructions an exam es
<br /> I& PART 1. Enter the cbatn of eventr-etaans, injuries, or compllu0ol s4hat directly caused the death. 00 NOT enter terminal events such a cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one coon on a line. Add additional lines If neasary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final 9) Emphysema
<br /> h
<br /> gleams or condition resulting
<br /> In death)
<br /> DUE TO, OR AS A CONSEQUENCE OF:
<br /> = orrld to death
<br /> Sequentially list conditions, If b)
<br /> any, leading to the cause listed
<br /> on line a.
<br /> DUE TO, OR AS A CONSEQUENCE OF: ! onset to death
<br /> inter the UNDEk4YING CAUSE C)
<br /> Idieeaee or Inlury that Initiated
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 16. PART 11. OTHER SIGNIFICANT CONOrriONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> IX ❑ YES ® NO
<br /> LL
<br /> W 20. IF FEMALE: 21 a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ❑ Not pregnant within past year Natural ❑ Homicide ❑ Driverloperetor
<br /> U ❑ Pregnant at time of death ❑ Accident © Pending Investigation ❑ Passenger ❑ YES NO
<br /> a. ❑ Not pregnant, but pregnant within 42 days of death ❑ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> a ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ sulfide ❑ Could not be determined ❑ Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br /> ❑ Unknown if pregnant within the past year ❑ YES ❑ NO
<br /> E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br /> 8
<br /> aSa 22d. INJURY AT WORK? 22s. DESCRIBE HOW INJURY OCCURRED
<br /> F
<br /> ❑ YES ❑ NO
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APTAO. CITY/TOWN STATE ZIP CODE
<br /> 23a. DATE of DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> " -April 7, 2010 1,2 1
<br /> qFq 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br /> 8 A riI 8 201 D 12:09 AM
<br /> E" -
<br /> 20, Oath trarealmykh.Wy[+dge, deem'-Md at in* um, date and place 29e. On the basis of oaaminationand/or Invenlaation. In my opinion death occurred at
<br /> H and tlse tome Gun(a) Stated. (Signature and Title) E the time, date and place and due to the nun(s) stated. (signature and Title
<br /> Donald Wirth, MD ~
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ® YES [NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO Not Applicable R 26a Is NO ❑ YES ❑ NO
<br /> 2 NAME, TITLE AND DR (PHYSICIAN, (Type or Pr n
<br /> Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> ~J April 9, 2010
<br />
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