|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />TFTE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE /�/��a�"�^�" � ' �"" "U -
<br />12/01 /2011 !� U i 2�� L� �� ASSISTANT STAO E REGISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />LINCOLN, NEBRASKA HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 11 03936
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S•NAME (Firat, Middle, Last, Sufflx) 2. SEX 3. DATE OF DEATH (Mo., Dey, Yr.)
<br />Clayton Allen Pelowskl Male November 20, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►s•) MOS. DAYS HOURS M1NS.
<br />Blanchard, North Dakota 79 March 13, 1932
<br />7. SOCUIL SECURITY NUMBER 8a. PLACE OF DEATH
<br />501-26-2202 OSPR ❑ inpaUe�rt OTHER ❑ Nuraing Home/LTC � Hospice Facllity
<br />eb. FACILITY•NAME pf not InsdtuUon, glve street and number) ❑ ER/OutpaUeM � Deeedeirt's Home
<br />�
<br />� 648 E. BisCheld ❑ oon ❑ o�t�er (spec�ry)
<br />�
<br />� 8�. CI1Y OR TOWN OF DEATH Qnclude Zip Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68801 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNIY 9e. CITY OR TOWN
<br />w Nabraska Hall Grand Island
<br />7 9d. STREET AND NUMBER 8e. APT. NO. 8(. ZIP CODE 9g. INSIDE CITY UMIT3
<br />�, 648 E. Bischeld 68801 � vES ❑ No
<br />� 70a. NU4RITAL 3TATUS AT TIME OF DEATH � Martied ❑ Never Marrled 106. NAME OF SPOUSE (First, Middle, Last, Sufftx) H wNe, give malden name
<br />� p nnamea, nue sepa�acea ❑ v+naowed ❑ nnmraea ❑ unicnown Darlene Phyllis Shelton
<br />� 71. FATHER'S-NAME (Flrst, Mfddle, Last, Suffix) 12. MOTHER'3-NAME (Flrst, Middle, Malden Surmame)
<br />m John Pelowski Helen Workes
<br />�' 13. EYER IN US. ARMED FORCES? Gfve dat� W aervice H Yes. 14a. INFORMANT•NAME 14b. RELA770NSMP TO DECEDENT
<br />E
<br />� �res, No, o� u�.) Yes 06/21/1949-05/03/1950 Darlene Ph Iis Pelowski Wife
<br />,� 1S. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (MO., Day, Yr.)
<br />F � Burial ❑ Do�tlon
<br />Laurie D. Sheffield 1397 November 26, 2011
<br />Q CremaUon Q Entombmerrt �gd. CEME7ERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Re�a� ❑ oure� �s�y� Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND NLAILING ADDRES9 (Street, CUy or Town, State) 17b. 21p Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />AUSE OF DEATH See instructlons and exam les
<br />1& PART I. Frrter the chaln ot evaMe-�diseaeee, InJuHee, or compticatlons�thet direafiy caused the death. DO NOT enterterminal eveMa euch ae cardiec arrest, ; APPROXIMATE INTERVAL
<br />reepiratory artese, or vartricular fl6riilatlon without showing tire etiotogy. DO NOT ABBREVIATE Ertter ony one cause on a Ibre. Add addiNonal Ilnee ti neceesary.
<br />IMMEDIATE CAUSE: ; o�at to death
<br />ux�owre cause ��� a) Myocardial infarction ; Immediate
<br />dleeaw ar condttlon reeultlnp .
<br />10 d �� DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s�,��y i�e �o�amo�, n b) Coronary Heart Disease : Years
<br />aeY, Ieaaing to tlte cauae tfatetl �
<br />on I�ne a DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />Fr�mr tlre UNOERLYIN6 CAUSe �� i
<br />(dieea� or InJury that In(tiatetl
<br />ehe evems r�umng In deafh) DUE T0, OR AS A CONSEQUENCE OF: : o�et to death
<br />t.asr dl �
<br />18;. PART tl. OTHER SIGNIFlCANT CONDITIONS-Comittions tontributing to the death but not resultlng In the undertyl� cause ghren in PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W Z0: IF FEMALE: 21a. MANNER OF DEATH 276. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED9
<br />� Q Not Pre9��in pastyear � Natural � HomidOe � DrivedOperetor �� � NO
<br />� ❑ Prepnant etbma adeath � Acdderrt � Pendlnp InveatlgaGon ❑ P e���
<br />� Noe Pre¢nant, nu� Pre¢naM wre,�n az aaye m aeaa, � Peaestr�an 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� � Not pregna�rt, but prepna�rt 43 daye to 1 year betore death ❑ s"�aae � coma not ne aecemu�ma ��� �5�� TO COMPLE7E CAUSE OF DEATH?
<br />� ❑ Unknown H P� �� me P� Y� ❑ YES ❑ NO
<br />a 22a. DATE QF INJURY (Mo., Day, Yr.) 2Zb. TIME OF INJURY 22c. PLACE OF INJURY�At home, fartn, street, tactory, otfice bulldi�, cor�sWctlon stte, etc. (Speclfy)
<br />E
<br />H wA
<br />.S 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />H
<br />❑ YES ❑ NO
<br />22L LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITYlTOVYN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />,� � .� �� November 22, 2011 Approx. 10:00 PM
<br />�� O 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIAAE OF DEATH �� Q� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />November 21, 2011 09:35 AM
<br />. ro sne eese m my enow�eaee, aeam oceurrea m ure ame, aa�e ana p�aee ��Z � 24e. On the I�sls ot examinadon and/o� InvesGB��. � mY aP�lon tleath occurted at
<br />�� and due to tlre cause(s) s�d. (Slgnature aml TfUe) ��� tlre d�. d�e and pWce and due to the cauee(e) sTeaetl. (Slpnature and Tttie)
<br />~� ~ o g Nancy Berger-Schneider, Hall Deputy County Attomey
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRIWTED?
<br />❑ YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES Q NO NotApplicable H28a Is NO ❑ YES ❑ NO
<br />27. E, TITLE AND ADDRESS OF C RTIFlER PHY I T, R ER P I OUN A ORNEY) ype or ri�rt
<br />Nancy Berger-Schnefder, Halt Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE � I �� 26b. DATE FlLED BY REGISTRAR (Mo„ Day, Yr.)
<br />November 30, 2011
<br />
|