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. -- STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH,
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR�ASK`R
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR �IIT.�C
<br />DATE OF ISSUANCE ��`��!�!
<br />11/14/2011 � p�, 2 p 15 7 0 ������ �
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<br />LINCOLN, NEBRASKA kt P+��,S�i/ICE�: '_
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERWICE9 :'��'�� ;�E� _
<br />CERTIFICATE OF DEATH �;a ; °; �',�
<br />DECEDENTS-NAME (Flwt, Middle, Lasf, Suffbc) 2: SEX �i `'� '` � DATE.O
<br />Richard Marshall Jolkowskl Male '� _ Noveri
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGH • Last BlRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY '' 8: DAT�_ a
<br />(Y�•) MOS. DAYS HOURS MINS.
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<br />near Arpdia, Nebraska
<br />SOCIAL 3ECURITY NUMBER
<br />506-30-3955
<br />i. FACILITY•NAME (Ii not InsUtution, gbe street and numberj
<br />Grand Island Veterans Home
<br />. CITY OR TOWN OF DEATH pnclude 21p Code)
<br />Grand Island 68803
<br />82 Feb►v;
<br />8a. PLACE OF DEATH
<br />HOSPITAL � Inpaqent OTHER � Nu�atng Home/LTC
<br />❑ ERlOutpaee� ❑ Decederrt's Home
<br />[) DOA ❑ Other (SPeaHY)
<br />aa. counm oF o�►ni
<br />Hall
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<br />���' �' 11 03717
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<br />)EATH ZMo., Day, Yr.)
<br />er5: 2011
<br />18. 1
<br />� Hosptee Faclitty
<br />Nebraska Hall Grand Island
<br />. STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 8g. INSIDE
<br />1407 W. 4th St 68801 ��s
<br />a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Never Married 10b. NAME OF SPOUSE (First, Mlddle, Last, SuHix) M wHe, give matden r�ame
<br />❑ nnaMed but separated ❑ Wldowed ❑ etioreea ❑ unic�wn Elizabeth Louise Rombach
<br />. FATHER'S-NAME (Flrat, Middle, Last, Suffix) 12. MOTHER'S-NAME (FUst, Middle, dlalden Sumame)
<br />John Jolkowskl Vivian Kaminski
<br />NO
<br />. EVER IN U.S. ARMED FORCESI G(ve datw of aervlee H Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yes,No,orunk.)Yes 01/10/1951 Be Jolkowski Wife
<br />. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 98b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� sur�at ❑ nonaUon Lau�le D. Sheffield 1397 November 8, 2011
<br />❑ CremaUon ❑ Errtombmerrt 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ otner (speeiry> W��awn Memorial Park Cemetery Grand Island Nebraska
<br />a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CKy or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />& PART I. EMer tlm chaln of eve�rts-dtaeases, InJurlee. or cpmplimtlons-that diracUy caused the death. DO NOT e�rter terminal everrte auch as cardlac azwat,
<br />reaplratory erreat, or ventricular fibNllatlon without shawing the e8ology. DO NOT ABBREYIATE. EWar only o�re cause on e Wre. Add addiGm�al Wres If �re�sary.
<br />IMMEDIATE CAUSE:
<br />namEOwre cause �� e) Alzheimers Disease
<br />dlaea� or condfdon resulting
<br />1° �'� DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequerttlauy pat eondNOrre, H b)
<br />enY. leadle9 to the cause ii�d
<br />on Ihre a DUE TO, OR AS A CONSEQUENCE OF:
<br />Frrtar the UNDERLYINO CAUSE . G)
<br />(disaa� or InJury that InlNatetl
<br />the e"a"te re�w"e i"'�tiq DUE TO, OR AS A CONSEQUENCE OF:
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<br />or�set to death
<br />> 1 Year
<br />0�84 to death
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<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS�Comlltiona eoMHbutl� to the death but not resulU� in the urrcleNyi� cauae given In PART I. 18. WAS MEDICAL EXANONER
<br />Coronary Artery Disease, Diabetes Mellitus Type 2, Chronic Obstrudive Pulmonary Disease OR CORONER CONTACTED4
<br />� p ves p No
<br />W 20. IF FENUU.E: 21a. NWNNER OF DEATH 216. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
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<br />� � Not DreBnant wfthln Past Year ��w� � Ho�aaa ❑ m�no��o, 0 res � No
<br />W Pregnant at Ume of death � Paseengaz
<br />V ❑ � Acddeirt � Pending Imestlgadon
<br />�T � Not pregna�u, but pregnant wkhln 42 daye ot desth � Petlestrlan 21 d. WERE AUTOPSY FlNDINCi3 AVAILA
<br />� Sutcltle � Could not be determhred TO COMPLETE CAUSE OF DEATH7
<br />� Not PreB�a�rt. but PreBnaM 49 Aaye to 1 year before death � Other (SP��Y) ❑ ❑
<br />� ❑ Un�mmm H pregnaM withln the past year YES NO
<br />�' 22a. DATE OF INJURY (Mo., Day, Yr.) Ylb. TIME OF INJURY 22c. PLACE OF INJURY•At home, tarm, atreet, faetory, offlce building, constructlon ake, etc. (Specify)
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<br />,� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑�s ❑NO
<br />?2f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYlfOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo, Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />November 5, 2011 � � �
<br />23b. DATB SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH � 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAI
<br />Z November 9, 2019 11:45 PM �� a�
<br />� � To tha besf oi rtry Iarowiedge, deatb oaurretl at the tlme. daDa end P� $��� 24e. On the basle oTa:eminatlon anNOr InveatlgaHon, ln my opinlon death occurred at
<br />� antl due M the ceuse�e) steted. (Signature entl Ttfla) � � thg tlme, date and plaea and.tlue to the musa(e) afatetl. (Signature antl T(tle)
<br />Gene L. Wyse, DO ~ g s
<br />� YES �J NO U PROBABLY �„J UNKNO�U YES � NO
<br />TIT AND ADDRESS O CERTIFI (PH CS II ATA5S�ST�A 7,��RO�R PH�
<br />Gene L. Wyse, DO, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br />. REGISTRAR'S SIGNATURE � �
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<br />If 28a Is NO
<br />i or Prlrrt)
<br />28b. DATE FlLED BY REG4
<br />November 9, 2011
<br />res u No
<br />(Mo.. DaY� Yr.)
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