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Zrauvrtlill STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 4/2/2018 LINCOLN, NEBRASKA 201802572 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY/. COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Romaine Ann Jolkowski 4 CITY STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hildreth, Nebraska 7. SOCIAL SECURITY NUMBER 508 -30 -8834 46. FACILITY -NAME (if not institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET ANO NU MBER 2224 W 10th St 10a. MARITAL STATUS AT : TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S,ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) •No 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other, (Specify) 20. IF'FEMALE: 7 ❑ Not pregnant Within past year ❑ Pregnant at time of death ❑ Nit pregnant, but pregnant within 42 days of death ❑ Not pregnant, bra pfegnent43 days Sol year before death ❑ tlnknbwn if ptegnaat within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY A WORK? ❑YES ❑ NO _ 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN I 28a. REGISTRAR'S a. DATE OF DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 5a, AGE - Last Birthday (Yrs.) 86 9b. COUNTY Hall M OS. 16a. EMBALMER - SIGNATURE Stacie L. Ruiz 22b. TIME OF INJURY 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23c. TIME OF DEATH 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) IGNATURE /1 � /� 5b. UNDER 1 YEAR DAYS HOURS 9e. APT. NO. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 2. SEX Female 5c. UNDER 1 DAY MINS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ® ER/Outpatient 0 DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 27b.IFTRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 2 4 a . SIGNED (Mo., Day, Yr.) March 21, 2018 24c, PRONOUNCED DEAD (Mo., Day, Yr.) March 18, 2018 9f. ZIP CODE 68803 14a. INFORMANT -NAME Wilfred Edwin Jolkowski 16b. LICENSE NO. 1495 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 3. DATE OF DEATH (Mo., Day, Yr.) March 18, 2018 December 30, 1931 6. DATE OF BIRTH (Mo.., Day, Yr.) 9g. INSIDE CITY LIMITS'' YES ❑ NO lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Wilfred Jolkowski 11. FATHER'S.NAME (First, Middle, Last, Suffix) George Tiaden 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Grace Casper 14b. RELATIONSHIP; TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) March 26, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery CITY / TOWN Grand Island STATE Nebraska 1712. Zip Code 68801 CAUSE OF DEATH, (See instructions and examples) 18. PART I. Enter the chitin of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Cardiopulmonary Cessation IMMEDIATE CAUSE (Final disease or condition resulting APPROXIMATE INTERVAL <' onset to death Immediate in death) Sequentiatty fist condindrts, any ;ieading to the eause tasted on linea DUE TO, OR AS A CONSEQUENCE OF: b)Pulseless Electrical Activity onset to deatft Minutes Enter the UNDERLYING CAUSE (dise •or mjury that Imtieted the.eyents resulting in death), LAST; • DUE TO, OR AS A CONSEQUENCE OF: C) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES : ®NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 10 NO 21d. WERE AUTOPSY:FINOINGS 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 8. NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH 12:03 PAIL:: 24d. TIME PRONOUNCED pEAD 12:03 PM w z o a O 2 24e. On the basis of examination and/or investigation, in my opinion death occurred at 2 z 8 the time, date and place and due to the cause(s) stated. (Signature and Title) F K U 8 Ashley A. Dorwart, Deputy Hall County Attorney 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑'YES CI NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ashley A. Dorwart, Deputy Hall County Attorney, 231 South Locust Street, Grand Island, Nebraska, 68801 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 21, 2018