2� 17���32
<br /> �t.,� r-.'r. �tYk,y yS Y n,� r 5�. �,rx ��.;.��� �.��,.��.;.�,r ��._..1,�� �°'i`ti{`r r;�'f r� .�. �....}f � - �,ti� r �;�};�.f .�y ..r, f � �+�+� {y,a
<br /> `i'R i'ti rs�, i` 4�.f� ��i'�x�,f � � :,Y• , �y��i;
<br /> �:� S '}.� rS ,{.�- �;�•� �.Y �,�s
<br /> ,�+e , . , -
<br /> .r �.•f ��,, . �. ,i .�.\ ----.. - --------------- --- � i�� y� ;3 i C'
<br /> STATE�F NEBRA�KA
<br /> ;;t�� a .x,E..�
<br /> •;�(i { Il,r/k,[R t�i�,l�i � ,;�:'.y��i.,,�.• r'1.1'a S•� �i. � .{ '�'�,,{,',?,i`�Y���. ��' ���r'xy �
<br /> r.•�i< <Y'1'� '�' :i:� �.��1...
<br /> ;k .. . .�". r� • ti..
<br /> P 1 FHE RAI F Fl . TA TE F NEBf�A SKA 1T
<br /> :�:;�::Hf�f�E1���F�`ir.S �C� Y GARR FS S �]. ��AL l?F � E � n
<br /> ...:::.; .:<.....:. ..;-...;
<br /> ,
<br /> . ;,- ,::;..,;:.
<br /> ,;: , ,. : ,
<br /> 1 R A
<br /> ::` �14�F�� :<::*HE ❑ MENT BEL W T Bf' A f���' : P�' �F THE OR GfNAt EC� D
<br /> ... .;
<br /> ::: <. �;:>.<,;,,.
<br /> ;
<br /> ,; .;.; .:- ::;
<br /> ... . .. ocu v o � ,:,,:,:.
<br /> ... � �.
<br /> ON F1LE WlfN THE NEBRASICA DEPARTMENT OF HFAtTN AND HUINAIV SERVICE5, VITAL __:`��
<br /> fi�C��;ipS.��FlCF,WN�CH IS THE LEGAL DEP4SlT�RY FDR;;V(TAL;REGQF�DS
<br /> --�
<br /> . �• -
<br /> �
<br /> �
<br /> �'.[�7�C;��'l���ti�`�E 5TANLEY S.C �PER -
<br /> ,,:: ,.:.:;;
<br /> � ASSISTANT STATE REGf5TRAR
<br /> �Z1�ZI���I� DEPARTI4�EAfT NEAtTH AND
<br /> .:
<br /> :::: :::, <:;::<;:._
<br /> HU1NA N SERVICES
<br /> ,,....;,
<br /> ::#.l��f�f N�L�1�[�JCA
<br /> .::. .:::,
<br /> �:.y ;:: ::;.: TATE DF NEBRASKA-aE T A MAN RVIC
<br /> S P�4FtTMEN3'�F H�aA�. H l+ft?.H11 5E ES
<br /> `' �:�: �.. ; .;i :::i i:= :::
<br /> CERT F
<br /> o ��� :. ..
<br /> ..
<br /> . . . .. ...
<br /> .:. . ,. ::,
<br /> I I C�4T�t3 F C�E,�4T`�
<br /> ..:�::
<br /> .:.. ..
<br /> 1,�EC�DENTS�NAM��(Fir�t, Midd[e, Last, 5uffix) 2.SEX 3.DA7"�DF DEATH tMo.,day,�r.y
<br /> Barbara Anng Zulkoski Fernale No�ember t S,2012
<br /> #;:CI'�'1!':�tNp ST`�l'��Q#��RRITQRY€3R FQREIGN CaIiNTRY�F BIRTH 3�i:ACi�r k.ast`f3ir#ida ' .LIPIQER 1 YEAR Sc.UNQER 1�AY 8.DA�E af BIF� A�a:C] `:�Yc:.
<br /> ;:::. ,,:.:.:..:..
<br /> ::.. . :.::.
<br /> ::. ,...::.::. .::. � , ...#.. �.,. �..,.t.:....:, .�tY. .:...�.: :;;.
<br /> tS. ::::
<br /> �. y...::
<br /> AY5 IiD[.lRS MINS.
<br /> :::r ..`;�s!,;;:. , :.k
<br /> �s. v
<br /> G.�rtcL a�d N���as a �� Mar h 24 � ..
<br /> c �
<br /> ..7.SOCIAE.SECURITY MUMBER 8a PLACE DF DEA�li
<br /> HDSPITAL �Inpatient �THER ❑Nursing Hame1LTC .�Ha�piqe�acility
<br /> ;- :..
<br /> ..,... ::..:..... .... .......:...
<br /> ..:::
<br /> !� .- ,....:.
<br /> ....:....
<br /> ,.::
<br /> ,....p.�,�1#.�TY�l��E�1�:ttQt 1r+atitutla�,giva atreet and num5ery ,
<br /> ..::. ..
<br /> ,„ ,,... ,..
<br /> ER�t#pnt�ent ❑Decedent's Home
<br /> :::;::�::;_;,
<br /> ...::.,: ..:: ;:.: .:..::..:.
<br /> :..::.:
<br /> ;:.:'�::;:� ; .,
<br /> �--<:: D4A Oth er 5�
<br /> ❑ c � �
<br /> �in#�rar� '�i�i d� I n er
<br /> fl �
<br /> s �aCet
<br /> > ; >
<br /> ; :
<br /> ;;
<br /> :::..:
<br /> ,. �
<br /> �:
<br /> ra::; ..,:. :. ,.::
<br /> > ;:
<br /> ;
<br /> ,,,:,_
<br /> ,,
<br /> ,,..
<br /> � $c.GITY�R T�WN nF DEATH�Includa Zip Cadey 8d.COl1NTY�F DEATFI
<br /> � �rand island G8803 Hall
<br /> :., ...
<br /> :.
<br /> .� d�
<br /> n�c:�ra. ;�,:>;;, ��.couNrr sc.cF�r oa�r
<br /> � � �� � _ owa
<br /> , :.: .
<br /> ...��..> . .
<br /> ; � ',k :;;;;i:: :�;: ::.::�::>�: _
<br /> r Hall
<br /> , ;<� >:;> :>
<br /> �;�, ; .
<br /> �� ..�b a�.a..... >:;
<br /> ...::;.
<br /> ,., ,
<br /> ,.
<br /> a
<br /> LL�9d S��TAfsiE�3�11114��Ft >:: ;: ; .APZ.H0. Sf.ZIP C�DE Sg.1#�I�IDE CI��#Mt"E'S > �
<br /> �, 5544 5o�,th 5�th Rvad �gg�Q ❑YES � No
<br /> �
<br /> � �Qa.MfkRITA�5TAT1tg=A.�11ME OF D�ATH�Nlarried ❑Never Married 146.:NAME:D�SP�IJSE[Frst,: Mid�le, I.�st, Suffixy If wife�gir►e maiden nam�
<br /> �.:::;
<br /> .,. ,....,;.,
<br /> :. ,:;::......:.: :..
<br /> ,.;,.,.::, .
<br /> ,;...-:::::
<br /> <:>:..:.::..:...
<br /> �::Ma�:." ".:�s " Wid�wed nknown
<br /> t��i:#��E � a�� Divarcesl U
<br /> , ,. ;:
<br /> ,... . ;�:::
<br /> ;:.;: .;:,.,::
<br /> ,.::.; .
<br /> r:;�::: .. �.. F�. ,. ❑ ❑ ❑
<br /> ; Ma�tin Antht�r�;; Zuiko��C�
<br /> , ::-:::: :..
<br /> �... .
<br /> ,,�,,._ .. . ..::
<br /> ..: .:. ..:.. . ,. .
<br /> y;::.
<br /> ,.:.,.
<br /> � 11.F�4YNIEF�'S=F�fIE:;�1�`iss�, Mfddte, L.ast, Sutiixy '�2.M.L7TH�R`S-NAM��First� MLddle, Malden Surname)
<br /> � Wavn� Meier 5harvn ❑enman . ..
<br /> a
<br /> IP.;
<br /> �13.EYE�t�M U.S ARM�Li F�RCES?Give dates af servi�e if Yes. 14a.INFaRMANT-N,4ME �4b.RELATfC�3�l H .TD D .E EHT :
<br /> �:.::�.:.;:;: ,...
<br /> :o:::; :
<br /> ;:;>.:. �::�:<:> ;::::�;:>:;.. ;;..
<br /> ,
<br /> : Y��[�"'or iJ�ik.: _>,
<br /> ;:.;,..
<br /> �:
<br /> . [...., �.. . l N.� . Martin Anthon Z�fl�� ki: ;; S ouse
<br /> <
<br /> <.>.:
<br /> ::15. ;.:T -::=5..�- '[fia.EMBA�MER�IGNI4TUR� .LIGEN5E NO. 15c.DATE M.`:� Yr:�:
<br /> �YFE.Hi�I7 DF fJ� P�a1Tl?E�N 7:6�
<br /> i:"
<br /> . N
<br /> ;.
<br /> -
<br /> ,.
<br /> .......::.:. ::..
<br /> �..::��
<br /> C?.':
<br /> .: ::,.. ;:.::> <::.:<>: . ::
<br /> ;:::.;..:.<:.
<br /> ,..... .......::
<br /> :.
<br /> :.:.:::: ... : :::..::.:::,
<br /> �urial ; ban�atian
<br /> ;-.:::
<br /> � Traaey Diatz �328 November 21,2012
<br /> ❑Cremation❑�ntnmbment ,��C�METERY,CR�1�lA7�RY OR O�'HEf�LQCA710N C[TY 1 TOWN STAT�
<br /> : al::�::; S eci
<br /> Q:#��[ri��► :. �he�...P �Yj
<br /> .....�.
<br /> :,:.'�_:;�a,;::::=,;::::::;:
<br /> ., ..
<br /> Alda Cemete Alda . �f� ��a <»
<br /> ;
<br /> �� .: :-.::.
<br /> ry
<br /> iT..,....
<br /> ::�::'1Ta'::; .L:: E AAi[]MAILING AQaRE55 5tree Ci �r Tnwn ! �4�.Z Co�l�. ::::
<br /> :>;:
<br /> ,:;:::,.>;:;:::
<br /> .
<br /> ,
<br /> ����� ..:...� � ...
<br /> ;
<br /> ,. ,
<br /> ::.. .,,:.,,. ,.
<br /> ... .,...:,
<br /> ;.;. ,,.,., ,;; <,;>
<br /> "' Aqfei�'un�r�l H�trie.1123 W.2nd.Grand Isfand.Nebraska ' �8��1 :
<br /> CALISE OF DE TH. ee' tru ' n d exam �es ..
<br /> :,.::
<br /> :. :.:.;:.. :
<br /> ' ;4�8:PM�T'!:�nter�Iia::�h�iti of avl�ti-�li�eases�ir�jurie=�or complitstin+►s�that direcfly r.pu�t�d tfi��cfeatl�:::�1b N0�eiltar ta[�shtalavents weh as card[ac ameat� �
<br /> APP Rpi�1M►kTf E1��ERV�Ri. :>::::::; :;
<br /> :;:: ;,..
<br /> � �
<br /> ;:ie�irat'.'8r. et v� �,ilar Tibrqletion withaat shvwi the etiol .pQ NpT AB�VIAi'�E.�ater or�1;vne C��r�..otf a line.Add add'rtional Ifnes if nace�
<br /> ...
<br /> ...,.:,...:.::: ;:...:::
<br /> ,:....:. P O!�► f�#� .:..:�.; n9 �4Y ...::• .,:'-;:
<br /> ,....:..::.....:
<br /> : :: .:: ;:::
<br /> ...
<br /> :
<br /> y ry, � :... :..; .:,:
<br /> :::::;: ::. .
<br /> .,.:.> ,.; , :,:,: :,:,.
<br /> .,, ,;,,.
<br /> ,
<br /> ::..::::.
<br /> � or►s,et to#��fh �
<br /> ,......, ....:. ..:.: ..:.......: IMAl1E01ATE CAIJ$E: ,..:
<br /> ��,��oui�cA�sE sF���� a1 Thymama,Malignant And Metastatic ; ; 2 Years:;;
<br /> disease or cv�dition rawltinQ �
<br /> ,
<br /> in tleath�::;.
<br /> � �1't t t��e��::
<br /> >::>::.
<br /> >:. D E T Oit A A C NSL� LiEMCE OF: se
<br /> :`::. :::. ::.:,,._,.:: ,:,:: U �, S � ❑ ;
<br /> ,..:..
<br /> ,..
<br /> �.
<br /> ,:...: - -
<br /> � ::..,-
<br /> .:...:.,..:;,. .::.:>: ...:....:�
<br /> ,
<br /> .:::
<br /> ;:>.S�<�:' E�sc��h' �r>:h
<br /> ,
<br /> ,
<br /> ,....
<br /> �,
<br /> -
<br /> :: ���: .
<br /> ,.
<br /> ,,;.
<br /> ...:,:.. ... .;.:: .-,
<br /> , , ;:,.
<br /> ::;:.
<br /> .,:.,:,. :
<br /> any;::[e,adi�:to tE�e_c,�ui�e 33�'`
<br /> ..:::.-::. :;.:
<br /> ,:..:::
<br /> ,.....:.
<br /> ...... ..-- ,
<br /> <_:,_<.:
<br /> ..
<br /> r►n liiie a::.;.. .....
<br /> ::••: ...: .
<br /> DUE Ta�DR AS A C�N5EDl]ENC��F: ; onset to death
<br /> Etrisr the tI�tI7ERLYINL3 CAUSE C� i
<br /> ,.
<br /> (diae8�:�=:injaryfll�t in�+�d
<br /> �
<br /> •-.::..
<br /> . ,..>.;;: :::.,,..,.
<br /> ,.:.
<br /> ,,.
<br /> `
<br /> ; ; ..:
<br /> the�.::.: ,,... �..
<br /> ,.:;
<br /> i'►.VR17t8. I :,,..,. ;:::. :.;,;. :•::•.,..,.,
<br /> <.:.:,.:
<br /> ��n��� :::.:�::::: ou�ro v�As A coNs�QUENc�aF: ;:: � o�,set�,�e��, ;�
<br /> ,...:. r
<br /> ..... _
<br /> u�:r: �
<br /> .
<br /> ,:::. <.,.<.-::,..: .:,.
<br /> ,..:.
<br /> , ;,,...:,. :;;:;,;:..:;;,
<br /> , d�
<br /> : .. ...._ .. :.::.>-
<br /> :::
<br /> .
<br /> �
<br /> ; , ;.: <:
<br /> ,.,,.,
<br /> ..:,;
<br /> ,,:,.
<br /> ..
<br /> :>:
<br /> :..:. � :.-:::::
<br /> ..:,.::.: ,
<br /> ,..:., ,
<br /> 18.PART II.OTHER 51GFlIFICAAIT C[3NaiTIDNS-Condltfans cantributing to ths deafh but nat res�lting in the underlying�ause given in RART I. 19.WAS INEQiCAL EXAMINER
<br /> ;Abn�r�nal MRI:Br���,:Pulmanary Hypertension Du�To Illness,S@iZl��@❑l��T�Illf1@S5 ;;�>:_ DR C�RDNER C�NTACTEd? .:.
<br /> � '
<br /> YES ":;:: D.. ;>�::>:: ':
<br /> ❑ �K..
<br /> ,..
<br /> ,,._.; ,., ..
<br /> ,,. ;:.:: ; :..:.: .;.::..:,::
<br /> , „ ...........:..:.: :; ,.;:.::.:
<br /> ..,,
<br /> F�;:.:. ... .:.;::.:. _
<br /> .:....::...... �;;�<� .:.....: ;
<br /> ::. ..... ;:..:
<br /> ..
<br /> �G;:�. ,.....
<br /> ;,....::,... :..,,,;...:,..
<br /> ,,.:>:
<br /> 30.#��EM�LEt.`�::� ::. 21a.MANNER OF DEATH .:. 21�i::lF>T�ANSPDRTATIDN lNJUR 21c.WAS AN AUTQPS�.R��F�R�F_4�`:.:� �
<br /> .:::.:.;:.::..,
<br /> �. ..:..::..,.
<br /> -
<br /> ....: .:,::.:.;:.: ;:..:.:.,:: ;
<br /> :..:.:
<br /> t�+�<> Not plti�qna�iE tivithiri pffst year lVatural Fiatnicide E�rF�erlflperamr
<br /> � � ❑ � �YE$ ❑Nfl ::
<br /> � �Pr�eqnant at time af death �AccideM �Pendin�In�astlqat�on ❑PBf��@�
<br /> -• NQ#•pr�4na�t..#ut pr�9Ranf rrithin 42 days of death P4destrfan 21d.WERE AUTOPSY:F!N WNGS AV►Al�.i46L.:.
<br /> '�::=:::->;,,>::: : ::: ;:ss.,:;,. Sukida Gouki i�o�t 6e.deiermined'::: ...:..:.
<br /> ,..
<br /> �:
<br /> ❑
<br /> da s 1 ar brfore dcath `Ot`'S TQ COMPLETE CAf�SE.�SF;Cl�ITkl�;. :-
<br /> '1Vot pf#�tiatdr:#tit jtil�a�rt�rK+13 Y ta ye . �er{pecifYy
<br /> ::.��:.:.:. ::.
<br /> ;:; �.
<br /> ::•:.
<br /> ' >
<br /> ,... ..:: ...
<br /> '�'a ';::. : ::::,:.:.:,. ;.::.::: ;:::
<br /> ::..:•.: ,::. :.,.,
<br /> �. •:
<br /> ;::,: ;:•:
<br /> :>:.:�,y';: YES 3�1�>.:.
<br /> .-.:
<br /> `�Jn��o�+if. n�ii#apiq�f�;n'thr past y�ar �
<br /> ;:.;.
<br /> ;
<br /> .�� .
<br /> �<-:
<br /> E. ��a.�ATE QF INJURY Ma.,Da,Yr. 22b.TIM�DF IN,1tJRY 22c.PLACE�F�NJURY-At home,fsrm,street,tacto o#(ice buildi
<br /> [ Y � ry, n�,canstructian si�e,etc.RSpeoifY�
<br /> v
<br /> �
<br /> ;:; ;
<br /> :,,,
<br /> :;: y// {��I t��
<br /> <;�:� d: Jl3 A:r::yy�.' �?:::.:ZZe.DESCRlBE HQW INJIJRY�CGLI �
<br /> ' �y.y� ,,::;
<br /> . ...... ..�T 5.�� ��.5. .S.'!�/�...... �'..''.''�•' :�..:. .,,..
<br /> ::::v::::
<br /> ;:�::;= >
<br /> ;,;;.,
<br /> ,:.. , ; ;
<br /> ;.
<br /> ;:;; ::: <
<br /> ,.:,. ;;:;::.::;<:;: :::i::: ;::
<br /> ;:..:::..::.... :.::.
<br /> Y�� N�=
<br /> ,:, � ..<.:.,:
<br /> :.:.
<br /> .
<br /> :: :
<br /> .. 22I.LD�ATl4N�F IM.11]F�Y-5TREE7�NUMB�R.APT.NQ. GITYlTOWN STATE ,,.:�IP G�O�
<br /> ,..
<br /> ,;;�3a.Di4'#'E f�l�A7H Mo.0 Yr. Z4a.[?AT�51GNE0 Ma.,aa,Yr. 24b.TIME D��EAT#�1 ;::` ;
<br /> <:;.:
<br /> ;;:.
<br /> ;:.::. :.::: ,.;,...,..
<br /> [ , �]►� ::.:>:;. :.:..:....
<br /> � Y :: ;.::::
<br /> :..:. ::::: <::;;:: ,,..z ;:�;::::::.
<br /> .:::.:: .:..::::.:.: .:.:. .::.::,
<br /> ; ::.:: ::.:
<br /> a:::::. g. '.:::.
<br /> ;::.:...
<br /> >:::.�' ;;. �;,1:- ,;�' �
<br /> ,=<;Na�sr� e S 2�12
<br /> .
<br /> U
<br /> .;.:..:.;,.. ,:
<br /> .... �;:.:::: .::.
<br /> :.:::":.:.: � ;.:.. :..•..... .,.,..-:. .:,...;.,..:. ;..:. _.,:... ...
<br /> ':.` ::;::.
<br /> ,:.::<. :.:
<br /> '::: :"::.=
<br /> ;
<br /> :.::.: � >:..;.. . ,-..:; ; = A Mo. a Yr. 24d.'f'IM�PRON �
<br /> :..��.A�l�l���+1�7{Mo.�Qay�Yr.� 23c.'FIME OF DEATH �Ic.PRt�NaDUNC�D I]� a� �D Y, 01�N��D�AQ..:;:�;;` �::°
<br /> ;::.. ::.:
<br /> .;::: :
<br /> ..,.>.:
<br /> _ ;:..:.:.:.:.:.::
<br /> ;:.:::..:
<br /> :::�x">�"::�; ..::::.; ,:,:.; '�::..: �.:::::,..: ..::.... :::.::.:::.
<br /> .
<br /> . �v i December 3 ��12 44:55 AM a a�
<br /> �a � 3d.Tq thv�vst pi my kr�orvledge,death vecurred at the tane,data and place �W�� �,p���gis af axaminatlnn andlor inveslipation,kn my opinion death ocr.urned at
<br /> oa xnd due ia the cauae�s�gtaisd.{8ipnature and Title) o p p tha time,date and p4ace and dua to the eauae(s�ptated.{Sipnsture rnd Title]
<br /> �..ue ,;:.:. . :.:_ ;:, �::�:v
<br /> ;>;-aE:::<;.:>; . G3:;.
<br /> .. ,.. ,,.:..
<br /> ;: ;
<br /> a..
<br /> , ...
<br /> �r� I;>�:<:; iCke ls 11lI ......
<br /> �Y..... ,
<br /> c.�:.:.::
<br /> N C�NStD�REE]7 ZBb.WAS C0�15EIV'�GRAN'i'�D� ;
<br /> �5.�1iD TL�►�:t���C��RIBRJ7E TD TFiE QEATH? 26a.HAS�R�AN UR TI�SUE�] ATic7�i 9E�1�
<br /> . B N :YE <>;::N� <: ...
<br /> ICN WN YE5 '''NO ' :>
<br /> Not A klcable if x a is � S D `'�
<br /> ....,. ,..:.:.:.;_:: .;. ;. ;:::::;;: ;:..;. ; ;:...,.:.;.;
<br /> ,.;..
<br /> ❑'YES '�N�`' �:AROBABE.Y ❑U N ❑ ❑ � ;:; p�+ L� � : ,;:;:.:.:.
<br /> 2T.NAME,TI'RE aN0 i�UC?R�SS�F CERTIFIER�Type ar Print) �
<br /> >,. ;:.. Ki.ml�erly�1;:;M#,ckels;�D,?�9 North Guster Avenue,Grand,lslar�d,N��raska�fi8�43
<br /> �:�
<br /> ,.�., .
<br /> ,:.. .......
<br /> A1'E FILE� Y RE 1STRRF�:wller: �r. ::::. :;=::: ;=;.
<br /> >::: .:..::
<br /> ,.:,.:.,...:.,,.
<br /> 28b.D B G
<br /> � R ....
<br /> � ;�8a;RFG1��'R��2:�SI�'a.a,IJmt"i�3 E ;:::: : :: >:: �: �..�Y . y..,.-.,.. ..;.;;. ,..::
<br /> �t ��
<br /> .�=
<br /> D cember 3 2012
<br /> ..: ,.:: :..:.. ,:..,;.:.. ,
<br /> e
<br /> ::�
<br /> . ,
<br /> .: :.,>.
<br /> ;:.� , ;,;
<br /> :.;,. ,-.
<br /> .
<br /> �
<br /> 0
<br /> :<;�
<br />
|