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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY G4RRIES THE RAISED SEAL OF T'HE WEBRASKA DEPARTMENT OF HEALTfl>)4ND H. UM�IN``3��]/ICES,, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA �r�r��cr�,q ,�I�EALTH AN� '
<br />HUMAN SERVICE5, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VTF �5 "'' .
<br />� � � �,' � � � ' � � '
<br />i �
<br />DATE OF ISSUANCE ,�r/�����^'�' � '� '' '
<br />� S,TAJltLEY S�GC=�PE �t' � t " i
<br />�C 1 �: 2011 . a� rArv�:�r���sr.ru►� �
<br />2 0�.1 Q 9 6"� G o��rHi�nn- oF,H�a�rw a�►�r� ,�
<br />LINCOLN, NEBRASI�__ _. -- -- H(�� �E yICES` � '� •
<br />3TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI�ES �' ��� �� ���'�� ��''' 4
<br />' CERTI C TE O DEAT i� �
<br />e. oecen�ure-Nnwe l�ra�. m�ame, �, surroc� z sex `� a� EA 1�2,DAY.�vr.�
<br />Donatd Loren Kell • Male Decembe� 7, 2011 ,'
<br />A. CITY AND BTATE OR TERRITORY, OR FOREION COUNiRY OR BIRTH Ba. A(iE-Lset BlAhday 6b. UNDER 1 YEAR Be. UNDER 1 DAY & DATE OF BIRTH (Mo„ Day, Yt.)
<br />(Y�e.) MOS. DAYS HOUR9 MWS.
<br />�rand Island, Nebraska'
<br />o b08-28-2477
<br />V 8b. FACILttY-NAASE (If rrot I�Utudon, give atreat m�d number)
<br />o VA Medical Center-Grand Island
<br />� 8c. CITY OR TOWN OF DEA7 H Qnelude ap Code)
<br />W Grand Island 68803
<br />? � 9a REB�DENCE-STATE ' � Bb. COUNTY � �
<br />r
<br />�, ' Nebraska Hall
<br />. ea sr�Er �wn Nume�
<br />� 1400 E. Abbott Rd
<br />� 10a MAWTAL STATUS AT TmAE OF DEATH � Married ❑ Navar Ma�
<br />m
<br />p ma�ea, �,n Ba�ma ❑ wraowea ❑ ntwfc.a ❑ u�xnown
<br />�' 11': FATHER'8-NAME (Flrat, Mlddle, Last, Sufflxl
<br />�
<br />� Robert Kell
<br />a�
<br />�
<br />� 13. EVER W U.& ARNIED FORCE89 Olve detes of service HYea. t4a INFORMANT-NAME
<br />O
<br />� �r�a, No, or unk.) Yes 01l18/1949-01 /12/1950 A nes Kell
<br />18. METHOD OF DISPOSITION 18a EMBAL 16NATURE
<br />❑BUrial QOonaUon .
<br />��re�� p�� "
<br />❑R�� pou,�esn�urt �sa. cmae�rexr. ct�uaroair oni6e �ocanoN
<br />Central Nebraska Crematibn Services
<br />17a FUNERAL HOmE NANIE AND MAILINO ADDRESS (34eet, City or Tovm, Stete)
<br />All Fa'iths Funeral Home, 2829 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions and example:
<br />IOwtlorts-thffimfeetiyaueetltde DONOTeNartWminaleaBMseuWaeCefdiaearta�,
<br />i ado�ogy.00 NOTABBHEVWTE Fstar uory o�re caum on a M& Adtl addWaaat Q�ree 9eeeesaery.
<br />81
<br />ee. PLACE OF DBATH
<br />HOSPITAL• Q InpadeM
<br />� ERlOutpetletR
<br />❑ �
<br />Bc. CI1Y OR TOWN
<br />November 20, 1930
<br />OTHER: � Nars�e8 HomelLTC � Hosptca FacWty
<br />Q DecedenPs Nome
<br />❑ Othe4ePeaHY)
<br />8d. COUMY OF DEATH
<br />Hall
<br />I s� arr. No. I 8f. ZIP CODB
<br />68801
<br />70b. NAME OF 8POU9E (Fl�et, Middle, Lest, SuFfl=) ti wife, gitra maldan nama
<br />Agnes Pawlowski
<br />72 MOTHER'&NAME (Flrst, Middle. Malden Sumame)
<br />Blanche Green
<br />7db. flELpT10N9HIP TO D
<br />Wife
<br />78c. DATE (Mo., �ay, Yr.) ,.
<br />December 10. 201'.
<br />IMMEDIATE CAU8E:
<br />IMAAEDUITE CAUSE (Flnal �
<br />diseaee or aonditlon resuitl�g a) f , .
<br />In deeth)
<br />UUE TO, OR AS A CONSE�UENCE OF:
<br />$equendatly Ilat co�tlone, B b) +�.,
<br />anY� leadl� to the ceuse Ilnted � Q.�1,1 t L'. � 0 \�C
<br />dn p � �' DUE TO, OR AS A CONSEQUENCB OR:
<br />EMer the UNDBRLYINO CAUSE �l ^�
<br />�a�� w in�u�y m�c waaoea W QC°' n� 10� _ C(1 � V P c,
<br />the evente resul8ng In daath) DUE TO, OR AS A CONSEQpENC6 F;
<br />Lnsr
<br />� l' nco�a��
<br />1& PART d OTHER BIOMFlCANT CONDITIONSComlitlone
<br />� 20. IF FEMALE:
<br />F ❑Not pregnant wlthln past yeer
<br />W ❑ P�9�� at Nme oT death
<br />V ❑ Not pregnant, but pregnatrt wlthin 42 daya of death
<br />!�
<br />.G �]Not pregnant, but pregnent 43 deye W 1 year befon
<br />� QUnknown Ii pregnaM withln the peat yeaz
<br />C
<br />to tite
<br />18b. LICENSE NO.
<br />cmrrowni
<br />Gibbon
<br />r�uitl� In the �mdedying cause given In PART L
<br />� 21 MANNER OF DFATH 216. IF TRANSpORTATION
<br />fleGUa1 Q HamiCide ❑ OrivedOparator
<br />❑ AealdeM � Pendin8 �9eBon ❑ Peasenger
<br />❑ Sutcide ❑ Could'nM be determined ❑ Pedeatrian
<br />❑ Other {SpecHy)
<br />STATE
<br />17b. ZiP Code
<br />� . ..�..........
<br />�
<br />� oneetto death
<br />i
<br />�
<br />i
<br />� orroet w daath
<br />i
<br />i
<br />�
<br />� onset to death
<br />i
<br />r i onset to deeth '
<br />J �
<br />�
<br />�
<br />�
<br />79. WAS WEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ 1� � NO
<br />21a WA8 AN AUTOPSY PERFqr21NED9
<br />❑ YES �NO �
<br />21d WERE AUTOPSY FlNOtNQB AVARABLE
<br />� TO COAAPIETE CAUSE 0(��, DEATH7
<br />❑ YEB ❑ NO
<br />O 22e. DATE OF INJURY (dto., paY, Yr.) 2Zb. TIME OF INJURY 22a PLACE OF INJURY-At home, fmm, etreat, factory, office bullding, eo�trucdon aRe, eta (BPecHy)
<br />v m
<br />� 22d. INJURYAT WORKT $2e. DE8CRIBE HOYV INJURY OCCURRED
<br />�'" ❑ YE8 �NO
<br />T
<br />2� LOCATiON OF INJUItY-STREHT R NUfdBER, APT. NO. CITYROWN STATE ZIP CODE
<br />Z3e. pATE OF DEATH (AAO., Day, Yr.) � 24a DATE SIfiNED (Mo., Oay, Yr.) 24b. TIME OF DEATH '
<br />'�i'� � pl V. ' a U� . � rtl
<br />� ,F,. � 23& DATE BIONEq (AAo„ Dey, Yr.) ZSa. TIMH OF �EATH '� � � y O r 240. PRONOUNCED DEAD (dlo, Day, YrJ 24d TIIdE PRONOUNCED DEAD
<br />� � Z� i
<br />$� a� � P C I �a� I qm o�ao m
<br />� V 23d. To the best oT my kiiow edge, death occurted et the dme, date aml plaee � iu � 24e. On the basis oT axaminadon and/m Imresdgatlon, in my opinion dea(h occurted
<br />� due M tfie c�uee( /, (Signature m�d TiUe) a� U at the tlme. date and piaea and flue to the esuse(e) etated (8lgnedue mrcl Tkle)
<br />0
<br />G/' M� ~ v`o
<br />28. DID TOB CO E BrJTE TO THE OEA 7 28e. HAS OROAN OR TI83UE DONATION BEEN CON9IDERED? 28b. WAS CONSENT ORANTED9
<br />r ❑ YE9 ❑ PROBABLY ❑ UNKNOWN ❑ YE8 NO Not Appticable Ii 28a ie NO ❑ YES ' O
<br />27. NAINE, TITLE AND ADDRESS OF CER77FlER (PHYSICUIN, PHY&ICUW ASSISTANT. CORONER'S PHYSICUW OR C011NTY A'iTORNE1h (1'ype w PriM) .
<br />� e' cZnl. a c a �l g�d
<br />28e. 6I8777AR'S StGNATURE ,( 28b. DATE FlLED BY REOISTRAR (Mo., Day, Yr.)
<br />P ' Lf/�it�s'i� ��iti,c�. DEC 1�3 2011
<br />e�. iNSroe crn ueerrs
<br />�Y�,QNo
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