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<br />STATE OF NEBRASKA
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<br />WHEN THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />4/27/2017
<br />LINCOLN NEBRASKA
<br />9a. RESIDENCE -STATE I9b. COUNTY
<br />Nebraska ' Hail
<br />in death);;.
<br />Sequential hJ llet r otaditie
<br />any, leash¢ to the. caus
<br />on line a
<br />9d. STREET AND NUMBER
<br />4693 South 60th Road
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Edward Lonowski
<br />EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No or Ut k.) Yes 04/05/1951-04/04/1954
<br />5. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />® Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />Enter the. UNDERLYING' ..RUSE
<br />(dise.*:ef injurytiiet in'ttteted,
<br />the events rexultingln death)
<br />LAST.
<br />0. IF EEMALE:
<br />❑ Not pregn past year
<br />❑ Pregnant at time of death
<br />Not y,ey' a nt,l,,,t prepnam w " 42 seas year death
<br />❑ Not Pregnant' but pfegnant.43 days to t year before death
<br />d prdgnare witfti i the past year
<br />❑ unknowe
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d_ INJURY Afl ORK?
<br />Q YES ❑ NO
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 21, 2017
<br />16a. EMBALMER - SIGNATURE
<br />Todd M Peters
<br />Central Nebraska Cremation Services
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Cerebral Vascular Accident
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />25b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />April 24 2017 01 :15 PM
<br />d. To the best Of my knowledge, death occurred at the time, date and place
<br />and d.re to t h' rq , „al. state,! (Signature and Title)
<br />Ryan, D. Crouch, DO
<br />201703512.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />14a. INFORMANT -NAME
<br />Alice Ann Lonowski
<br />u. CITY On TOWN
<br />Aida
<br />7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Peters Funeral Home, 302 Second Street, PO Box 181. St. Paul, Nebraska
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />CAUSE OF DEATH (See instructions, and examples)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />Sui C,uv = mat -i,J, .* G$rerr. „ :.Ea
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BE
<br />❑ YES 50 NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska
<br />❑ Passenger
<br />1 Pe. _rt: an
<br />CI Other (Specify)
<br />avei
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donald John Lonowski
<br />4. CITY!ANO STATE OR TE RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Loup City, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />324-24-0815
<br />$b. FACILITY - NAME (If not Institution, give street and number)
<br />4693 $OUth 60th Road
<br />O
<br />1-
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />a Aida 68810
<br />5
<br />. AGE - Last Birthday
<br />(Yrs.)
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 21, 2017
<br />6. DATE OF BIR'
<br />November 25, 1932
<br />(MO., Day, Yr.);,
<br />9e. APT. NO.
<br />lob. NAME OF SPOUSE (First, : Middle, Last, Suffix) If wife, give maiden name.
<br />Alice Ann Jarzynka
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Loretta Ignowski
<br />F
<br />161a. LICENSE NO.
<br />I 1078
<br />Gibbon
<br />9f. ZIP CODE
<br />68810
<br />PANT). Enter the chain of events - - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />tespiratoty errett, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) End Stage Dementia
<br />disease or condition resulting
<br />'18: PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />GhrOnic Pain,S Stenosis, Hypertension
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo Clay, Yr.
<br />April 26, 2017
<br />STATE
<br />Nebraska
<br />17b Zip'Code
<br />68873
<br />APPROXIMATE sIN: ERV
<br />onset to death
<br />1 Year
<br />onset
<br />3 Yea
<br />onset to death
<br />onset t4 death`
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21 b. IF TRANSPORTATION INJURY! 21c. WAS AN AUTOPSY PERFORMED?
<br />❑ Driver /Operator
<br />❑ YES ® NO
<br />2 ".d. WERE AUTOPSY FINDINGS AVAILABLE.
<br />TO COMPLETE CAUSE OF D EATH ?
<br />❑ YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Speci
<br />CITY /TOWN
<br />N CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES
<br />28b. DATE FILED BY REGISTRAR '
<br />April 25, 2017
<br />9g. INSIDE CITY LIMITS
<br />❑ YES ®NO
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />
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