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STATE OF NEBRASKA, �' ';, , ,�,�rt,�,��,�,�� �
<br />WHEN TWIS COPY CARRIES THE RAISEQ SEAL OF THE NEBRASKA DEPARTMENT �F,HEA�]�ND,HU"�►kA�AI ��/�S; �T, CERTIFIES
<br />THE BELOW TO 8E A T'RU� COPY OF THE OR,t'GINAL RECORD ON FILE W1TH 7HE 711E�5'K�4. D f�' � At��F, H�E�I L�'FFf ;AND
<br />HUMAN �ERVICES, VITAL RECORDS OF�FICE, WHICH IS THE LEGAL DEPOSITORY � � � ? R 9l�1"�I��✓ `'�: `.. "�';;'
<br />R +� > � �� .
<br />DATE IOF ISSUANCE '
<br />3 wj '��`;
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<br />� JA�1$ �, 201t a�5�nrr�rar� a-�is�,a�z `; n
<br />� 012 � 0�617 a ���,� � �F`������ r .r
<br />LINCOLN, NEBRASKA - --- _ H�Ii�T�l�il,�.$S �,�� ; � '� �� �� "`
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN 3EIiVICE3'� �, ����� �,: �
<br />CERTIFICATE OF DEATH 3 � �
<br />Stanley A Armatys Male J�nuary 15, 2011
<br />4. CfIY AND STATE OR TERRffORY, OR FORQON COUNTRY OF BtRTH 6a AQEWt Birfhday , 6b. UNDER 1 YEAR 6a UNDER 1 DAY & OAIE OF BIRTH �Yo„ Oay, Yr.)
<br />(Yre.) Mt]�• DAYS NOUI� NIINB.
<br />� Cedar Repids, Nebreska = 85 - May 7, 1925 �
<br />I. 80CU14 SECURITY NUMBER 6a PLACE OF DPJITH . _
<br />6�4-gq4g: �. : �asmru: p i�eai!s�a. . .. ���I:Nweie� �ra�rc ,. . .- :[j xo�a�o Fa�ar�y. . .
<br />Bb. FACW7Y-NAbtE (I( not 4tediNtlun, BWe al�t end number) , ❑�RfOUtpada�t � DeoedenYa Homa .
<br />Tfffany Square Care Centar � °OA �
<br />- 8R. CITY OR TOWN OF DFATH (G�clude Zip Cade) ¢d. ROUNIY OF DEA7H
<br />Grend �sland 88803 Hall
<br />� �e. RE8IDR.NICH-STATE . 9b. COUNTY 8e CITY OR TOWN •
<br />�, Nebreska Boone Cedar Rapids
<br />� a Ad. BTREET AND NUAIIBER 9a APT. NO. 8f.21P CODE 8g. INSIDE CITY LINIITS
<br />1413 390th � � 88627 � Yea � No
<br />10a MARI'�AL STATUS AT 71M8 OF D 7H � MaMed [,) Navm Man78d 70b. NAME OR 8POU88 (Fl�t, PBlddle, Last,' BuHix) H wife, oWO meltleN neme.
<br />� � eear�ea, �n.�, C7 wieowea O ni.or�«, _ p u�� ' Th � . . _ , . . .�...
<br />eresa M Armatya
<br />p 11. FATHER'9-NAAAB (F6at, EAltldle, Last, Suftix) , 12 fdOTNER'&NAME (Flrst, OAlddie. Nletden SumamoJ
<br />S �tanle Arma a V leria Micek
<br />� 13. HVER IN U.S. ARAAED FORC�$? t3lva detes o1 aervke HYes. 14a INFOR4AANT.NAASB 146. RELATIONSF�P TO DECEDENT
<br />F .
<br />ll'ea, No, m Unk.l Yes 05/09l1945-1 TherBSa a Sp�OUSe
<br />1& METHOD Op D18POSRION 18a. �S TURE 18b. LICEqISfl N0. 18a OATE (AAo., Day, Yr.)
<br />�� ��°" � Janua 19, 2011
<br />�w�mo� pe�n
<br />p� ��v�n �aa. ceae , crurxa on+ , i.ocaroN - emrrtowni srn�re • .:
<br />� " St Anthony's Cetholic Cametary • Cedar Rapfds • --Nebraska
<br />17a. FUNERAL HOAlE NAAAE ANd MNLINO ADDRE83 (S6'eaR City or Toxm. Stete) 77b. Zip Code
<br />Levander Funeral Home, , Cedar Rapids, Nebraska _____ �_ .68627
<br />� CAUSE OF DEATH (See Instructions and exam les •
<br />10.PARTLEaOnMe .mseum,Injwbs,weomP��am�ldettliextlyausadthsdeaM.00NOTer�rtmmWlsre�arcEqm�o�nen. � ;APPRDXIMATEWTERVAL
<br />�.tasp4rtory nasL awa6lwW R6riWtbn wkhaR �herrfnY tlm qiolom. DO NOT ABBRfiVtA7B.6N�ranlY on oup on � Ihro. Add �dditlaW Ma V mamry.
<br />I►AdIEDIATE CAU$E: i OnsBt l0 tl88fA
<br />IdIElEDIATE CAUSE (Flnel y.- �� f
<br />aleoaee or cmMfaon reawa� a) � (�'A `� ��'/1� � d= �' /�-e'J�f d �? `
<br />In,deafh) t.
<br />DUE T0, 0 AS A CONSEQUENCB 0�: � death
<br />8equentlelly dnt condtdm�e� H bl
<br />rs�sY. laa6ng to Yta srt��'rmt� � . .
<br />on qire a DUE T0, ORAS R CONSEQUENCE OF: ; onaet to death
<br />EMarflre UNDERLYINt3,GWSE ,c)
<br />�m6eaea m Mjury tl�t �nW�d 'DUE TO, OR AS A CON9EQUENCH OF: ; o�et � death
<br />Yhe evante rewtNng 4� deatt�}
<br />LABT
<br />d)
<br />18. PART IL OTHER $I�NIFICANT CONDITtON&Conditlo�re coMribiWnp to fMe tleath but not resWtl� In the unAeriyinp eause ghren in PART L 1& WA81dEDICAL EXAININER
<br />� . , . .. . . . . _ . , OR CORONER t�NTACTED?' _. . .
<br />, .. » . ❑ YES NO
<br />�� ❑ H EATH 21b.1E TRANBPORTA'�ION INJURY 21a.YYA81W AU7QPSY PERFhRTdED7 ....,
<br />20. IF FEAAALE: .` .: ., 21 NANNER OF
<br />�� pregnent vrlthin peat year N mnieida ❑ DAverlClparatm ❑ YES �NO' ,
<br />L.I � at tlme of dmth ` , ❑ Ao¢Idmrt 0 Pendinq ImesUpadon ❑ Peseen9sr
<br />V � ?ld. NfERE AUTOP$Y FlND1Ni3S AVAILABLE
<br />. Ll N�e a��. a�e n►�� wwu� az aays �r n� ❑ smmaa ❑ Cwld irot be determined ❑ Pedestrimtl ' TO COIWPLETH'CAUSEOR CEATHT_
<br />.� 0 Not pre�anR 6ut Pregnant 4� days to 1 year baforo dea8� ❑ Other (BP�h�) ❑ YES a� NO
<br />� QuNmown a prAgnaet withYn are nast yea. ��C
<br />E �a. DATE OF MJURY (Mo.� DaY. Yr.) ?36. TIdIE OF INJURY 22c. pLACH OF INJURY�1t home, tarm, �'eet faetory� bfltce Wdldie9� eonshucUon sits, etc. (SP�tY)
<br />t ' m
<br />Q 72d. INJUIiY AT WORI(4 4Ze. bESCRIBE HOW INJURY OCCURRED
<br />� ❑ YE8 ❑ NO
<br />_ � a
<br />-- � �r . j :._.......�.. , . .
<br />. �. .....� � e . .e*�:.. .. . .. .. ... ,.. ,.... . , :., .. . .
<br />2N LOCATION OF INJURY • BTREEt NUM�ER, APT. NO. CI7YROWN .� , r• • ' BTATE� -. 2iP CODE
<br />23a. GATE OF
<br />� � x�n. enr�
<br />$ � o ! �,
<br />� xW. Ttl fhe�
<br />.� � and due W
<br />I�
<br />ZB. D!D TOBA USE CO
<br />,' ❑�, ; Q� `;�.?�
<br />27. NAME� 71TLE AND ADO
<br />Dr. Travis
<br />ze�. aeoisTRna�s s�c�uua
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<br />Dey, Yr.)
<br />Yr.)
<br />44a. DATE 81GNED (Mo„ Day,Yr.) 24b. TIME QF GFJITH
<br />,��� m
<br />23a TIME OF pPJ1TH m �� Q� 14a. PRONOUNCED DEAD (�Ao., Ddy, YI.) 20d. TriNE PRONOUNCED DEM
<br />0 - '� B F ''
<br />m
<br />m� at tha time, dam m�d plaae", �+ ��� aAe. On the 6Wa of e:and�mtlon'endlor Inveatlgetian. in my opMion death ocaaiad
<br />etura mM ,$ � � ffi tlro tinre. date and plaee a�ttl due to-tlre eauaefs) s�ted. (8lgnadus and TiBe)
<br />. . � � s r �� . .
<br />,.....,.. _., ,,. � 9 V � . . . ,
<br />2ee. ru�s oRC�uw o� n e wmoN aee�i coHSiceaeo� �. 2eti. was cons� or�wr��� `_ :.. _
<br />NN , ❑YES, k0 ....NotAPP���eHZBaisNO.:.
<br />�IW� PHYSICUW A9pti$TANT. CO NER' PHY8iC1AN OR COl1NTY ATTOAN�Y) Cr7fPa � P�M) �
<br />729 N Custez Av Gr�nd Island ,NE�68$0� �
<br />� 28b. DATE RILED BY R80ISTRAR (fda� DaY� Yr.)
<br />�`�a �1i• 'L . , JAN 2 7 201�
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