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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND.1:1WAI N SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL FlEC � M FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICU N, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. 4', DATE OF ISSUANCE MAR 19 an LINCOLN, NEBRASKA 20150 ASB1ST s . A N Y s Bt CO . TA G AR � HE XH ANLI STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAt S CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Irene Marie Lewandowski 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Farwell, Nebraska 7. SOCIAL SECURITY NUMBER 508 -32 -4720 8b. FACILITY -NAME (N not Institution, give street and number) 524 N. Custer Ave. 9a. RESIDENCE -STATE Nebraska 10a. MARITAL STATUS AT TIME OF DEATH IXR Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Edward Waltman 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 16. METHOD OF DISPOSITION M Burial ❑Donation ❑cremation ❑Entombment Removal OOBUr(specify) (disease or Injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST 20. IF FEMALE: allot pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑Unknown if pregnant within the past yea 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑ NO 23a. DATE OF DEATH (Mo., Day, Yr.) 130 February 25, 2008 r oO10 e 23d. To the best of my knowledge, d Q and due to ause4s) stated -- and Tide) , , ; :/97r 23b. DATE SIGNED (Mo., Day, Yr.) 3-? ° Z< 9j 22b. TIME OF INJURY 25. DID TOBACCO USE CONTRIBUTE TO THE D TH? ❑ YES 1;1NO ❑ PROBABLY ❑ UNKNOWN 23c. TIME OF DEATH 7:48 a. ccurred at the time, date and place 5a. AGE -Last Birthday (Yrs.) 79 913. COUNTY Hall 16a. EMBALMS NATURE 21a. MANNER OF DEATH pt Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL: 0 Inpatient ❑ ER/Outpatient ❑ DOA 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9d. STREET AND NUMBER 524 N. Custer Ave. 28a. REGISTRAR'S SIGNATURE 5c. UNDER 1 DAY HOURS BINS. OTHER: O Nursing Home/LTC ❑ Hospice Facility lI Decedent's Home - 0 Other(Spaclfi) Ed. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9e. APT. NO. 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 71,NQ 9f. ZIP CODE 68803 14a. INFORMANT -NAME Al Lewandowski 18b. LICENSE MET Y, CREMATORY OR OTHER L e CATION - MET Y, CREMATORY OR OTHER L CITY/TOWN Westlawn Memorial Park Cemetery Grand Island 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) ts. PART L Enter the chat, were„ re . diseases, 'Mudge, or complications- that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory anent, or ventricuter nbnlletion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on • line. Add additional Was it necessary. IMMEDIATE CAUSE: 15. PART IL OTHER SIGNIFICANT CONDITIONS- Condilons contributing to the death but not resulting In the underlying cause given in PART L go/14 21b. IF TRANSPORTATION INJURY ❑ DdvedOperator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) '3. * DATE 'OI DEATH (Mo.,Day,Yr.) February 25, 2008 8. DATE OF BIRTH (Mo., Day, Yr.) October 10, 1928 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES MAR 5 2008 9g. INSIDE CITY LIMITS Yea 0 No 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) B wife, give maiden name. Al Lewandowski 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Helen Czapla 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day, Yr.) February 29, 2008 STATE Nebraska 17b. Zip Code 68801 IMMEDIATE CAUSE (Final disease or condition resulting a) in death) (OL /atrlgh Cer I APPROXIMATE INTERVAL onset to death I -: �I- I onset o death ye Sequentially list conditions, R b) any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: on line a. Enter the UNDERLYING CAUSE c) DUE TO, OR AS A CONSEQUENCE OF: onset to death d) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ki NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 'RNO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH m x u rc s 'o a O. a_ a p y O O W 24e. On the basis of examination and/or investigation, in my opinion death occurred O C C at the time, date and place and due to the cause(s) stated. (Signature and TRW) V ~ ((.1 0 24d. TIME PRONOUNCED DEAD m NO 27. t /1511 TIT AND DDRE o CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR C ATTORNEY) (Type or Print) Ctcm li e , :D., 2116 W. Faidley Ave., a0 Grand Island, Nebraska 68803 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) i x .' • Fent r ,.