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<br />WHEN THIS COPY CARIBES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$TICS4WftkN WCH IB
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - --
<br />DATE OF ISSUANCE
<br />ANLEY S. COQmRc
<br />11/19/2004 200502127 AS*STANT f.iArE*3tIS7W AR_
<br />LINCOLN, NEBRASKA HEAL TH AND f(UMIIK'SEFlV _*S$i'STEMw
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEI VTCES'F1 ANGEANll CIPP(3�t�I
<br />VITAL STATISTICS -
<br />CERTIFICATE OF DEATH =-0 4 12 5 9 8
<br />1. DECEDENT - NAME FIRST MIODLE LAST
<br />2. SEX f.m."
<br />.3. -P f OF DEATH (Month. Day. Year)
<br />Lester Klinkacek
<br />Male
<br />November 9, 2004
<br />4 AND STATE OF BIRTH (Il not in U.S.A.. name country)
<br />5a, AGE • Last Birthday I
<br />UNDER t YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH iMonth. Day. Year/
<br />MOs, l DAYS
<br />5c. HOURS MINIS.
<br />St. Michael, Nebraska
<br />(Y's.) 56.
<br />7
<br />march 22, 1925
<br />7. SOCIAL SECURTIY NUMBER
<br />$a. PLACE OF DEATH
<br />506 -28 -1433
<br />HOSPITAL; ® Inpatient OTHER: ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />Bb. FACILITY - Name (It not institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other ($peci vi
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d, INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® - Nd ❑
<br />-- Hall
<br />9a. RESIDENCE - STATE
<br />91b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREETANDNUMBER (tnctuding Zip Code)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Cairo
<br />406 W Medina St. 68824
<br />Yes ❑X No ❑
<br />10. RACE - (e.g., White. Black, American Indian.
<br />11. ANCESTRY le.q.. Italian, Mexican, German, etc)
<br />12. F-] MARRIED ® WIDOWED
<br />13. NAME OF SPOUSE (If wile. give maiden name)
<br />etc.) (Specify)
<br />White
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />I
<br />Zella Smith
<br />14a, USUALOCCUPATION (Give kind of work done during most tab.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even it retired)
<br />Elementary or Secondary. (0.12) College (1 -4 or 5.1
<br />Farmer
<br />Own Fam
<br />12
<br />1(3. FATHER -NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Joe Klinkacek
<br />Ruth Schmidt
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a, INFORMANT - NAME
<br />Yes no. orunk.) 8 w4ar 0of
<br />47Patricia Hill
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R,F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />P.O x 1844,,,,- Lyons, Colorado 80540
<br />20. E LM - SIG TV LI NSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />211. DATE 21C.
<br />CEMETERY OR CREMATORY NAME�',y„
<br />® Burial ❑ Removal
<br />?
<br />Nov. 12 2004
<br />Limn Lutheran cIG«et
<br />2a, rUNCRAL HOME - AME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Rasmussen Mortuary
<br />❑ Cremation ❑ Donation
<br />Buffalo mt Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.r,O. NO., CITY OR TOWN. STATE, ZIP)
<br />311 Grand Avenue - . v ' NE 68869
<br />23. I�� CAAAU,fS�E /r�YIW /�� TENT LY yO'NE�CA[U'BE PER LINE FOR lal, Ibl. ANq. (c)l Intervaldetween onset and deals PAR!8
<br />� � ' i S ' LO� V •`^� ONE
<br />v
<br />V4V- '. I I N V - " .
<br />DUE T¢Q,RR ASS'AACONSEOUE CE F' Interval between onset's deatn
<br />cel
<br />I
<br />DUE TO. OR AS A CONSEQUENCE OF: Itilerval between onset and death
<br />I
<br />(c)
<br />OTHER SIGNIFLCANT CONDITIONS - Conditi s contributing to the death but not related PART
<br />PART n t ( PREGNANCY
<br />,D�gf(,p,
<br />III IF FEMALE. WAS THERE A 2a
<br />IN THE PAST 3 MONTHS?
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />//�J
<br />A'
<br />(Ages
<br />10-541 Yes No
<br />Yes No
<br />Vas No
<br />26a.
<br />25b. DATE OF INJURY (Mo.. Day. Yr..)
<br />26c, HOUR OF INJURY
<br />26d, DESCRIBE HOW INJJRY OCCURRED
<br />❑ Accident ❑ Und8termined
<br />M
<br />❑ Suicide ❑ Pending
<br />260. INJURY AT WORK
<br />26L 0P a ju"IdnNJeU�RY /Shog, farm. Street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />2713. DATE OF DEATH tMa. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. YO
<br />28b TIME OF DEATH
<br />y
<br />l l q- Dq
<br />rsL
<br />M
<br />�a
<br />y
<br />27b. SIGNED (Mo... D(a�,y. Yr,) 270. TIME OF DEATH
<br />F � �
<br />28c. PRONOUNCED DEAD lido.. Day, Yr)
<br />28d. PRONOUNCED DEAD /Hour)
<br />1DATE
<br />�+ a
<br />a
<br />27tl. To the best of my knowledge. d stn ocnurrod at me time, date and place and ue tv the
<br />12 g 2130. On the basis of examination and, or inveetigatien, in my opinion death occurred at
<br />`�
<br />cause(s) stated.
<br />the time, dale and place and due to the cause(s) staled.
<br />(Signature and Title) �
<br />(Si nature and Title) ►
<br />29. DID TOBACCO USE CONyTRRIIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 3NTED?
<br />❑ YE$ Iv/ I NO ❑ UNKNOWN
<br />❑ YES NO
<br />ES NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (type or Print/
<br />ichar-d M. Fruehhi :0406 C7ranj IStalld. NE 4M
<br />32a REGISTRAR
<br />32b.,DATE FILED BY REIM "Al 1 '100 n
<br />r
<br />yL
<br />5
<br />LEGAL: S90' of W131.5' of Lot 1, Block 1, Ingalls Turner Subdivision and N23'
<br />of 5113' of W131,5' on Lot 1 Block 1, Ingalls Turner Subdivision, Cairo, Hall
<br />County, Nebraska
<br />u
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