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1 DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />grM
<br />- OF DEATH (Month. Day Year)
<br />Eugene Thomas Placzek
<br />Male
<br />T
<br />n y
<br />a. CITY AND STATE OF BIRTH Ittrrotdr USA.. name Country)
<br />5a. AGE - Last Birthday F
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />c z
<br />m
<br />o
<br />rri
<br />5C. HOURS' MINIS
<br />n o
<br />= D J x
<br />-I
<br />N
<br />CD
<br />CAD
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home
<br />® ER Outpatient ❑ Residence
<br />ae-�
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(SpecAV,
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />9d INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Q
<br />p
<br />Hall
<br />9a RESIDENCE -STATE:
<br />F�
<br />O m
<br />S M
<br />>- Tan
<br />F-"
<br />o
<br />C
<br />y
<br />Nebraska
<br />U.i
<br />Grand Island
<br />615 Pheasant P1. 68801
<br />Yeb ❑ to ❑
<br />10. RACE - (e. g., White. Black. American Indian
<br />a) O IIJJ
<br />r Cn
<br />1 13 NAME OF SPOUSE /d wife give marten name)
<br />etc .I lSbecdy)
<br />White
<br />(Specab)
<br />American
<br />-_
<br />Claire Gates
<br />o
<br />C0
<br />15. EDUCATION (Specify only highest grade completed)
<br />En tV
<br />O 3 0
<br />or working life, even it reliredl y.. -
<br />Insurance Agent
<br />Life Insurance
<br />16. FATHER - NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Michael NMN Placzek
<br />Mary Unknown
<br />18 WAS DECEASED EVER IN U.S ARMED FORCES? �19. INFORMANT - NAME
<br />O
<br />No - Claire Placzek
<br />I
<br />7-( m
<br />eas tit P1., Grand Island, Ne. 68801
<br />20Z,� B.LMER -SIGN UR CEN 21a METHOD OF DISPOSITPQN
<br />L_
<br />21b. DATE 21c CEMETERY OR CREMATORY NAME
<br />h � Burial 011. moval
<br />rd �-
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOV;N STATE
<br />11, FUNERA OME NAME
<br />❑Cremation ❑Donal:on
<br />�.I
<br />Grand Tstand, Nebraska _
<br />22b FUNERAL HOME ADDRESS (STREET OR R F.D. NO.. CITY OR TOWN STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (cp Interval cdeath
<br />N
<br />rd. I~
<br />\
<br />lal � 1 , �~ s"'�'.""' _
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onsel and death
<br />Ibl I
<br />DUE TO OR AS A CONSEQUENCE OF 1 Interval between onset and death
<br />-ti
<br />rnz
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />of IF FEMALE. WAS THERE A
<br />25. WAS CASE REFERRED TO MEDI AL
<br />PART PREGNANCY
<br />�11.AUTOPSY
<br />IN THE PAST 3 MONTHS'(
<br />"1
<br />L
<br />y EXA :!U:EP, OR CORONER'+
<br />(Ages
<br />WHEN TM COPY CADS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />Ys No
<br />Yes L No
<br />26a
<br />25b DATE OF INJURY (Mo.. Jay Yr)
<br />SYSTEM, IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORRAVALE WITH
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Acadent Undetermined
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS T iS
<br />M
<br />O THE LEGAL DEPOSITORY FOR VITAL RECORDS =
<br />26e INJURY AT WORK
<br />26f PLACE OF INJURY At home. farm . street factory
<br />Q
<br />NomiCltle Invesllgal�on
<br />❑❑
<br />U DATE OF ISSUANCE
<br />200107038 = ==
<br />o "¢e budding. etc ;Specify)
<br />JUN + 0 1998 ASSISbAS
<br />WI
<br />I
<br />27a DATE OF DEA
<br />Vt)
<br />rd z LINCOLN, NEBRASKA HEALTH AND HIM&SLdR!/ICES SI*T" C,
<br />28a DATE SIGNED (Mo Day Yr)
<br />28b TIME OF DEATH
<br />.�f/7Mo jDay
<br />rd
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERid M SUPPiqiFT
<br />i
<br />M
<br />44 VITAL STATISTICS
<br />0- 7
<br />-
<br />27b DATE SI NEED] (MO. ay Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD fmc, Day, YrI
<br />28d. PRONOUNCED DEAD (Noun
<br />CERTIFICATE OF DEATH - -_ -
<br />��
<br />Ok, M
<br />i
<br />1 DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />grM
<br />- OF DEATH (Month. Day Year)
<br />Eugene Thomas Placzek
<br />Male
<br />T
<br />May 20, 1998
<br />a. CITY AND STATE OF BIRTH Ittrrotdr USA.. name Country)
<br />5a. AGE - Last Birthday F
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH - (Month. Day. Year)
<br />Columbus, Nebraska
<br />(Yrs) 64 5b
<br />MOS 1 DAYS
<br />5C. HOURS' MINIS
<br />September 22, 1933
<br />7 SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />507 -32 -3919
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home
<br />® ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (H nol institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(SpecAV,
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />9d INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® No ❑
<br />I
<br />Hall
<br />9a RESIDENCE -STATE:
<br />9b. COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />Bit. STREET AND NUMBER /Including Zip Code)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />615 Pheasant P1. 68801
<br />Yeb ❑ to ❑
<br />10. RACE - (e. g., White. Black. American Indian
<br />1 I. ANCESTRY le .g.. Italian. Mexican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />1 13 NAME OF SPOUSE /d wife give marten name)
<br />etc .I lSbecdy)
<br />White
<br />(Specab)
<br />American
<br />NEVER DIVORCED
<br />MARRIED
<br />Claire Gates
<br />14a. USUALOCCUPATION /Give kind of work time during most �.� lab
<br />KINOOFBUSINESSMDUSTRY t
<br />�('
<br />15. EDUCATION (Specify only highest grade completed)
<br />Elementar or Secondary (0 121 College 11 -a or 5.1
<br />I 1 _
<br />or working life, even it reliredl y.. -
<br />Insurance Agent
<br />Life Insurance
<br />16. FATHER - NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Michael NMN Placzek
<br />Mary Unknown
<br />18 WAS DECEASED EVER IN U.S ARMED FORCES? �19. INFORMANT - NAME
<br />(Yes. no or unk.) (11 yes give war and dates of services)
<br />No - Claire Placzek
<br />I
<br />i 19b ! NFORMANT MAILING ADDRESS (STREET OR R.P D NO, CITY OR TOWN. STATE. ZIP)
<br />eas tit P1., Grand Island, Ne. 68801
<br />20Z,� B.LMER -SIGN UR CEN 21a METHOD OF DISPOSITPQN
<br />L_
<br />21b. DATE 21c CEMETERY OR CREMATORY NAME
<br />h � Burial 011. moval
<br />1 May 232 1998 Grand Island City Cemete
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOV;N STATE
<br />11, FUNERA OME NAME
<br />❑Cremation ❑Donal:on
<br />Livingston - Sondermann F.H.
<br />Grand Tstand, Nebraska _
<br />22b FUNERAL HOME ADDRESS (STREET OR R F.D. NO.. CITY OR TOWN STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (cp Interval cdeath
<br />�betwwee/ynn oon�sellaanndd
<br />�.�.�.
<br />ART C`4m-&�
<br />' , � " h t
<br />I I
<br />\
<br />lal � 1 , �~ s"'�'.""' _
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onsel and death
<br />Ibl I
<br />DUE TO OR AS A CONSEQUENCE OF 1 Interval between onset and death
<br />I
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />of IF FEMALE. WAS THERE A
<br />25. WAS CASE REFERRED TO MEDI AL
<br />PART PREGNANCY
<br />�11.AUTOPSY
<br />IN THE PAST 3 MONTHS'(
<br />"1
<br />L
<br />y EXA :!U:EP, OR CORONER'+
<br />(Ages
<br />10 -5A( Yes No
<br />Ys No
<br />Yes L No
<br />26a
<br />25b DATE OF INJURY (Mo.. Jay Yr)
<br />2f, HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Acadent Undetermined
<br />M
<br />7 S ,de F-1 P-cinq
<br />26e INJURY AT WORK
<br />26f PLACE OF INJURY At home. farm . street factory
<br />26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />NomiCltle Invesllgal�on
<br />❑❑
<br />yes No
<br />❑
<br />o "¢e budding. etc ;Specify)
<br />I
<br />27a DATE OF DEA
<br />Vt)
<br />28a DATE SIGNED (Mo Day Yr)
<br />28b TIME OF DEATH
<br />.�f/7Mo jDay
<br />XpJ
<br />i
<br />M
<br />o �
<br />a Q >
<br />27b DATE SI NEED] (MO. ay Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD fmc, Day, YrI
<br />28d. PRONOUNCED DEAD (Noun
<br />��
<br />Ok, M
<br />i
<br />M
<br />27tl. To the best Of my k e.. ath cut the time, date and place and due to the
<br />s a.sefs) stated. `KVJ
<br />28e. On the basis of examination and or investigation, in my Opmon death occurred at
<br />the time, date and place and due to Me cause(s) stated.
<br />_
<br />(Signature and Titlel ►
<br />ISi nature and Title
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DIE ? 30.a
<br />HAS ORGAN OR TISSUE NATION BE NfiliGNSIDERED9 30D
<br />WAS CONSENT GRANTED'
<br />Y/ ❑ YES ❑ NO UNKNOWN
<br />- I7Y -ASS X
<br />YES ❑ NO
<br />31. M AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type or Print)
<br />Q ► A . 'i� S • �o w � P �j- ti..1t- `� le --� ►5 8ga 1
<br />32a. REGISTRAR
<br />_1141� /
<br />32b. DATE FILED BY REGISTRAR /Mia. Day Yr)
<br />JUN 8 1998
<br />y,
<br />
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