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<br />RFTTTRN T(�� _Snhn R_ McIlermntt, P� flnx� 4h0, Grand Ts_7_and, DiF �'i88II2 ____-__ -
<br />RE: Lot 3, Jones Addition City of Grand Island, Hall County, Nebraska
<br />, ; ,{'�, ,"
<br />WHEN TH/S COPYGIRJt1ES TF� RAISED SEAL OF THE NEBRASKA HEALTH A_NF��Jd� S�R!/l¢:ES �' _
<br />AIF
<br />SNSTF.M, IT CERTIFlES THE BELOW TO 8E A TRUE COPy OF THE p�RIN�����'a����' ��� �;� :
<br />THE 11fEBRASKA HEALTH AND HUMAN SERIRCES SYSTEM. VITq�. STi���'F�?7�-�N E� „�: '
<br />THE LfOAL DEPOS/TORYFOR VITAL RECORD3 �" � - "''� ' { �4 � '
<br />���� `f �{ �'
<br />DATE OF %SSUANCE I " z _ ` , � ' �'
<br />4�2��ZOOS 201200818 - = _� -� ���R �E
<br />�' " ���r�nr�+�� � a �
<br />L/NCOLN, NEBRASKA HEA�.TI�I,/�I�HFl�A�S���� , `! ,
<br />� r'' � ,.,
<br />STATE OF NEBRASKA DEPARTMLNT OF HEAL1gi'ANA HUN�E�CF.�IIVAII�E'.� SU� ,�RT' �
<br />- ,��. ���� , � � , ;.4rfi� 3 . �, 0 4 0 8 3
<br />CERTIF'ICATE OF� bEA'�i ; ° -�- . , , , i � ,
<br />t. DECEDENT-NAME FlRST � MIDDLE � LAST � . � �� Z'�'SIX,- .;. �.� AtE'OFDEATII,,{ry}bnth,pay;��Yeer/
<br />�, -
<br />Arnold Eugene Walahoski Ma.le Apr3.T lI; 2003 �
<br />4. CITY AND STATE�OF BIRTH /!lnat In U.SA. name cnuntry) � Sa AQE - Last BUthday UNDER 1 YEAR UNDFA 1 DAY & DATE OF BIRTH lMontl� Dey. YearJ �
<br />Elyria, Nebraska ��' 74 s��MOS DAYS Sc.HOURS� MiNS. September 15, 1928
<br />7, SOCULL SECURTIY NUMBER Ba PLACE OF DEATH �
<br />508-32 HOSPRAL: [� u orHea: � NursingHome
<br />Bb. FAqUTY-Neme (NnotinstiMlcrt�9fvestreatendnumberl � ER�WPaBeM � Fleatdence
<br />St. Francis Medical Center � D0A �
<br />8c. CITY. TOWN OR LOCATION OF DEA7H Bd. INSIDE CI1Y LIMITS Be. COUNTY OF DEATH
<br />Grand Islans�� NQbraska_ - ------ = �-�=.,� �.1�- .- - - -
<br />9a RESIOENCE - STA'f� 9b. CAUMY 8c. C(N. TOWN OR L6CATION &i. STREET AND NUMBER (!ncludngZ/p Cadel 9e. INSIDE CtTY UMI'fS
<br />Nebraska Hall Grand Island 218 S. Oak 68801 `'� �"°�
<br />10. RACE -(e.g, Wfilte. B�ack Amerlean �I�en. 17. ANCESTRY lag- �tellen. Mexleen. Qerman� e1c1 � 72 � MARRIF� ❑ WIDOWED 13. NAME OF SPOUSE (Uwi1a 9ive ma/den mm�el
<br />�`�� White � Polish M�� DIVORCED Lucille Ann Lilienthal
<br />14a USUALOCCUPATION IQ�������9� 14b. WNDOFBUSINESSINDUSTRY 95. EDUCATfON �Specilyonryhigheffigredecompleted�
<br />Nworldn8lHa, even NietFiedl - �emeMarY or SeaondaN f0-12) � Cotle9e It -4 or 5+1
<br />Truck Driver Grocer Distribution . 8th Grade
<br />t& FATHER-NAME FIRST � M�DDLE - LAST 17. MOTHER FlR3T MIDDLE MAIDENSURNAME
<br />Joseph Walahoski Anna Grabowski
<br />1& WAS DECEASED EVERIN U.8 ARMED POACES7 18a INFDRMANT-NAME
<br />IYes. no. w wk.l In ves. 8� war e�d dates'ol serv�cee)
<br />No --------- Lucille Walahoski
<br />19b. INFORMANT MAILWQ ADDRESB � (STREET OR R.F.D. N0. CITY.OR TOWN. 9TATE. ZIP) . - '-
<br />Lucille Walahoski 218 South Oak Gran@ Island, Nebraska 68801
<br />Z0. EMBALMER - SIGNATUFE 8 UCENSE NO: � 21 a� METHOD OF DISPOSI710N 21b. DATE � 21a CEMETERY OR CREMATQRY - NAME
<br />Not Embalmed ❑�,�, �] �,�„� April 11, 2003 Westlawn Mem�. - Park Cremator�
<br />22a FUNERAL HOIdE - NAME 27 d CEMECERY OR CREMATORY LOCAl10N - CITY OR•TOWN STATE
<br />Livingston.-Sondermann F.H. �`�°" � Grand Island Nebraska
<br />22b, FUNFAAL HOME ADDRESS .(STREET OR R.F.D. NO. CIN OR TOWN, STATE, ZIP) .
<br />601 North Webb Road Grand Island, Nebraska 68803
<br />23. IMMEDWTE CAUSE ' (ENTER ONLY ONE CAUSE PER LINE FOR le�. (b�, AND �q) I Wervai between oreat and deam
<br />j I
<br />`��( i ,�" 1,'^>` l� S,S�� �v� io-ti ,� e�u.v'� i Y �" �9 3"
<br />DUH TO, OR AS A CONSE�UEN OF: I hrterval n oreet a�M deaN
<br />1
<br />1C roi �.4na-- � � r � Gt rt ' X � � � � -
<br />' � OUE TO, OR AS A CONSEOUENCE OF: � �� �����
<br />I
<br />1 �
<br />IC) � � / d u i
<br />OTHER SI�NIFl DI710NS • Canditlone conMbutlng to the death but rrot rel6tetl PART III IF FEMALE WAS THFAE A 24. AUTOPSY ?S. WAS CASE REFFARED TO MED�CAL
<br />pqp7' � pREGNANCY IN THE PAST 3 MONTHS7 EXAMMER OR CORONER7.
<br />II � t � L! �7.� � ���L�'iK��� � . IA9� 10-54) . Yes No � No X Yes No
<br />26a, 28b. DATE OF INJURV (Ma Day. Yc) 2BC. HOUR OF INJURY 28d. DESCRIBE HOW INJURY OCCURRED
<br />� Actident ❑ Ut�delermirred M
<br />� Suicide � PertN� 28e. INJURY AT WORK 26t. o PLA� E QF �NJU�H ��11 home. ferm. sb'eet �ectnrY 2 B9• LOCATION STREET OR RFD. NO. CRV OR TOWN STATE
<br />(fl bU11Cp�g, /BCnY/
<br />. � Hamicide ImeaUgatlon Yea � No ❑ .
<br />I 27a DATE OF DEATH /Ma. Day. Yr.l � � , �a DATE SI�NED �Mc.. Day. Yr.l 28b. TIME OF DEATH
<br />� g � �1 /�3 .�� M
<br />� � 27b. DATE SIGN /Ma.. Oay. Yi) 27c. TIME OF DEATH �� Y 28c. PRONOUNCED DEAD (Ma. Dey. Yil � PRONOUNCED DEAD (Hmvl
<br />�� � x �/ �� 3 � X .� A M �' a°
<br />� ��� �
<br />r� 27d To tlre beat of my krrowied �� et - i/ � due to tlre 2 B e. O n M e � i e o f e x e M n e don ar�Nm �^� in m y opiMon deazh occurred et
<br />ceusefsl s�d.
<br />�� s the mn& dete arm ptace and due ro tl�e ceusals) s�d. .
<br />I Sl naNre arul Title ► nawra ar�d Title
<br />28. DID TOBACCA USE CONTRIBUTE E DEATH4 � 3Qa HAS OR(iAN OR TISSUE DONATION CANSIDERED4 3Ub WAS CON9ENT aRANTE��
<br />X � YE6 NO � UNKNOWN � �� YES B NO � YES ,� NO
<br />31. NAME AND ADDRESS OF C FlER (PHYSICUW, CORONER'S PHYSICUW OR COUNTY A7TOANEYI fTyAe aPdrtll ' �
<br />Dr. Chad Vieth, M.D., 2116 W. �idley Ave. Suite 400, Grand Island, NE 68803
<br />32e. REOISTRAR _ � - 32b. DATE FlLED BY RE�ISTRAR /Ma Day. Yr.l
<br />y.�D
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