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� �\.,f� I <br /> � <br /> ��\ `' �... m A � <br /> � � �� C m v, <br /> � �.� _ � � ,� - <br /> c� , ` � � .i � o .�".� Q ..3'�.. <br /> �� �- z � '7v <br /> ��a C� � � z -� � � � <br /> �,1�''�' �. a� � � '� o ��3 � <br /> \� �� I �� � � Z G'a <br /> ` �� e� � s m � ~ <br /> � rn � rD-' � � � <br /> � � r A O <br /> an v� ee� <br /> (\�jc�.; � � � � <br /> �� �, � � � � <br /> �� (,J'1 v'`.i � <br /> � O � �a O <br /> WFEN TF�S COPY CARf�S THE RAISED SEAL OF THE NEBRASKA HEALT�F�/ZVICES C\ � <br /> SYSTFII�IT CERT�S Tlf BELOW TO BE A TRUE COPY OF THE ORI(31AS�tL��O�ItQ�WITH J� � <br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL ST�TL�S�70H1��11j�//S � <br /> THE LEQAL DEPOS/TORY FOR VITAL RECORDS = = - - ---�_= - �\ <br /> DATE OF/SSUANCE '2 4 O�0���� _ - __ �`�-_�=`-' -� <br /> MAR 3 0 1998 =-== - � - � E�R <br /> �$S/S�i11(�'STAT�R�I��AR <br /> UNCOLN.NEBRASKA HEALTH AN�HUMAIK9�S Sl�°IEM <br /> STATE OF NEBRASKA-DEPARTA�TTT OF HEALIH AND HUMqb1 gERVi�,S�'Q,T�4�1EE�PORT <br /> VffAL STATISTICS -- _-- <br /> CERTIFICATE OF DEATH — <br /> 1 OECEDENT-NAME FIRST MIDDLE LAS7 2 SE% 3.DATE OF DEATH /Monlh.Oav.Yearl <br /> Thomas N A Kluska Male March 10, 1998 <br /> 4.CiTv AND STATE OF BIPTn �nrrofn USA..name caunlryJ Sa.AGE-Last Birlhday UNDER 1 VEAR UNDER 1 DAV 6.DATE OF BIFTH /Monlh,Day.Yeai/ <br /> IYr51 Sb MOS. � DAVS Sc.HOURS MINS. <br /> Girard , Kansas 78 � July 11 , 1919 <br />� 7.SOpAL SECURTIV NUMBER Ba.PLACE OF OEATH <br /> 510-18-4 2 8 5 HOSPITAL � inpaUent OTHER � Nurs�ng Home <br /> 8� FACIU7V�Name /llnp/inslifufiOn.givBSheefandnumbB/J � ER OutpaGent � Res�tlence <br /> Community Care �1 America � DOA � Other/SpecAv� <br /> & G7V TOWN OR LOCATION OF DEATH BA.INSIDE CITY LIMITS Be.COUNTV OF DEATH � <br /> Grand Island �B5 � N� ❑ Hall <br /> 9a RESIDENCE-STATE 9b COUNTY 9c.CITV.TOWN OR LOCATION 9G.STREET AND NUMBER /Inc/Win9Zp Codel 9e INSIDE CITV UMIT$ <br /> eb�aska Hall Grand Island 932 E . Do����l �e=�] �[� <br /> 10.RACE-(e.g..W�ite.Black.Ame�¢an InOian. 1 t.ANCESTRV�e.g_Italian.Mexican.German,etcl �� t2.�MARRIED ❑WIDOWED t3.NAME OF SPOUSE lll wAe o��e maiden name/ <br /> eic.r ISceaNI ISpeciy� • NEVER DIVORCED , � <br /> M e Ri�ch <br /> taa USUAI OCCUPATION /G�ve kiMol work done during mos( �� 14b KIND OF BUSINESS INDUSTRV n�C� 15.EDUCATION �Spat�ly oniy h�ghes�graAe comple�eA� <br /> ol worbnq/rle,even Arehre0l ('1 � �� Elementary Or SeCondary 10�12� College I I-0 or 5-I w <br /> Auditor `J <br /> duca ' on 12 �- <br /> 16.FA7HER-NAME FIRST MIDOLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br /> � <br /> •John Kl�ska Mar Elnicki <br />� 78.WaS DECEASEU EVERiN US ARMED PORCES? 19a.WFORMANT-NAME <br /> iVes.no o�unk.� �4 yes g�ve war and da�es d 5ervice5 <br /> ' I (� <br />� 02/13/42 - 10/0 Son ) � <br /> �9b �NFORMANT MAILING ADDRESS ISTREET OR R.F D NO.,qTV OR TOWN STATE.ZIPI --— <br /> 2107 Pioneer Blvd . Grand Island Nebraska 68801 � <br /> I 20'EAI�LMER-SIGNATURF.8 LICENSE NO /A,�'/ 21a METHOD OF DISPOS�TiON 21b.DATE 21C CEMETERV OR CREMPTOA� NAME 1 <br /> L� - _'�� ;� v �� <br /> - / � , � �a�.�a� �Removai 3-14-98 'nglevale/Fairview Cem.t�� � - <br /> I 22a FUNEAAI.HOME�NA 27tl CEMETERV OR CAEMATORv LOCA7iON CI7V OR 70WN STATE , <br /> I <br />� K�e 7 n e ❑Cremation ❑oo�a��o� E n g 1 e v a 1 e , K a n s a�: � ! <br /> 22D FUNERAI HOME ADURESS ISTREET OR R.FD.NO.CITV OR TpWN.ST4TE.ZIP� "�"�-�� i <br /> ��i � w _ nr�rth Frnnt c��r�r�d �l�n� �I�e}aras]ca fi� A-3 � ` <br /> 23. IMMEDIA E CAUSE EN7ER ONLV ON CAU�E ER LW ial bi AN �c11 � Imerval between onset a:��� � � i <br /> PARa� �` \^"'`,�V" \� �V\v� 1 ' \�N��i- _'" <br /> DUE TO,OR AS A CONSEOUENCE OF i Intervai ben+een onsel ana aeam � <br /> ;b� <br /> i <br />� DUE TG.OR AS A CONSEOUENCE OF- ' imervai De�ween onsei hnu aeam <br /> I Icl � <br /> i <br />�� OTHER SIGNIFICANT CON�ITIONS-CaWilions contriDuling to the tleath but no1 relatea PAR7 III IP FEMALE.WAS THEFE A 24 AUTOPSV 25.WAS C/+SE REFERRED TO MEDICAL <br /> PART PREGNANCV IN TME PAS7 3 MONTHS? EXAMINER OR CORONER� <br /> i II �. <br /> (Ages�0-541 Yes No ves No Ves Nc <br />� � 26b DATE OF INJUFV /Mp_Day.YrJ 26t HOUR OF INJURY 26d.DESCRIBE HOW INJURV OCCURAED <br />� � Acutlenl � Unaeierm��netl M <br /> � Suk�tle � �'antl�ng 26e iNJURV AT WORK 26t.PL CEOf MJUFiV-At�ome,farm.sireei.�actory 26g.LOCATION STREE7 OR R,�:i NO. CITv OR TOWN STAtE <br /> � ❑ ❑ oflice building.etc /SpeciNl <br /> � Nom�citle invesngauon Ves No <br /> I 27a DATE OF DEATH lMo.Day.Yr./ 2Ba OATE SIGNED ItiW.Day.Yrl � -:ME OF DEA7'� ! <br /> 3- ��-- � � - � � <br /> $��'n 27G DA7E S�GNED IMo.Oay.Yrl 27c 71ME OF DEATH �i� 2Bc PRONOUNCEO DEAD iMo_Day.n./ 28d.PFONOUNCED <br /> �"0 3- �3-�� J c�,0 M ��=o <br /> g� g , <br /> 27tl To me Oest ol m nowledge. e occurr�time.tla�e ano�pl e arid due to��e ��H 2Be.On the basis d eRaminatbn arM�a imesagaiion,in m��^c <br />� causelsl siaiea. Me nme.date an0 place antl tlue to Me causels)statnn <br />�I ^ �S�naiure antl 7�t�e�� �(�� ��^�\��- M� �S�nature antl TiMe► <br /> i 29.DiD TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a NAS ORGAN OR TISSUE DONATION BEEN CONSIDERED� 30.b WAS CONSENT GH� <br /> � VES � NO �UNKNOWN � YES �NO � YE.:. _ . _. <br /> 31 NAME ANO ADDRESS OF CEFTIFIER IPHVSICIAN,CORONER�S PHYSICIAN OR COUNTV ATTORNEVI /Type pPrinp - <br /> t <br /> John Cannella M.D. 9 u er Ave . Grand Island NL . � <br /> � <br /> 32a REG�S7RAR 32D DATE FIIED BV REGISTRAR /Ab.Ca� <br />� • M�� � i 9� <br />