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<br />e 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 />10/14/2021
<br />LINCOLN, NEBRASKA
<br />202110981
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />21 13513
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent residedat the time of death. I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Lawrence Joseph Klimek
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 26, 2021
<br />4. CITY ANDSTATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day. Yr.)
<br />Loup City, Nebraska
<br />(Yrs.)
<br />73
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />May 4, 1948
<br />7. SOCIAL SECURITY NUMBER
<br />505-64-0011
<br />8a. PLACE OF DEATH
<br />HOSPITAL '❑ Inpatient OTHER ® Nursing Home/LTC 0
<br />Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d, STREET AND NUMBER
<br />26 Via Trivoli
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDECITY LIMITS
<br />® YES ❑ : NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Billie Ritchie
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Frank Klimek
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Loretta Kaminski
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 03/26/1968-03/25/1970
<br />14a. INFORMANT -NAME
<br />Billie Klimek
<br />14b. RELATIONSHIP TO DECEDENT'
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Q Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16b. LICENSE NO.
<br />1092
<br />16c. DATE (Mo., Day, Yr.)
<br />October, 1, 2021
<br />Cremation ©Erttorribment
<br />Removal " ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Grand Island Nebraska
<br />17a. FUNERAL
<br />Curran Funeral
<br />HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PART I. Enter the chain of events- -diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additions) lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (final a) Intraparenchymal hemorrhage
<br />disease or eonditionresulfing`
<br />onset to death
<br />2 Weeks
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to: the cause listed
<br />on a.
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYPIGCAUSE C)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Dementia,hyperter s(on,parkinsons disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within pest year
<br />Pregnant at time of dean-
<br />0
<br />21a. MANNER OF DEATH
<br />Ei Natural 0 Homicide
<br />❑Accident ❑Pending tnvastigltlort
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />'❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />1:3 YES ®NO
<br />0: Not pregnent, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />❑Suicide ❑Could not be determined
<br />❑-PedasMan
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Ma., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc, (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 26, 2021
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 6; 2021
<br />23c. TIME OF DEATH
<br />02:50 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. Tothe bast of my knowledge, death occurred at the time, date and place
<br />and due to Mecause(s) stated. (Signature and Title)
<br />Ryan D Crouch, DO
<br />24e.. On the basis of examination and/or investiga ion, in my opinion death occurred et
<br />the time, date and place and due to the cause(s) stated. (Signature and Tide);
<br />25. DIP TOBACCO U$E CONTRIBUTE TO THE DEATH?
<br />0 YES ',® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES 0 140
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D Crouch, DO, 800 N Alpha St, Grand Island,
<br />Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE)
<br />L._ �t ...14_,$) .67",,,f-ka.-,-k L
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 11, 2021
<br />
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