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STATE OF NEBRASKA '
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMEN�ERTII
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH IIIQ� T=
<br />HUMAN SERVICES, VITAL RECORDS OFFICE WHICH IS THE LEGAL DEPOSITO
<br />DATE OF ISSUANCE
<br />09/18/2015 9,02201697
<br />3
<br />VIGS
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTHbitJMAN,j s'
<br />CERTIFICATE OF TH F`,�
<br />I. DECEDENT'S -NAME (Finn. Middle, Last. Suffix)
<br />Wayne Frank Rakosky
<br />�5
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />AGE - Last illi hday . VN02R 1 YEAR ,tie, NDM 1 OA`M ;
<br />(Yrs.) Mos, DAYS HOURS
<br />Burwell, Nebraska
<br />89
<br />7.50 IAL SECURITY NUMBER Be.
<br />PLACE OF DEATH t
<br />506-26.0649
<br />I +
<br />HOSPITAL (]nwdat le [3ureing HafReICTC , Q
<br />rgedt �t04csdeRNs tlornl� : " t
<br />EiRItP tyll
<br />FACILITY -NAME (If not nstittrtWn, give direst amfnbsrtum
<br />0
<br />t r
<br />4057 Manchester Road ° `►
<br />' I "
<br />80. CITY OR TOWN OF DEATH (htclude Zip code) '
<br />Rd GOUPCIY A119 : s
<br />;
<br />Grana island 68803
<br />Hai -n
<br />Sit: RES NCB -STATE
<br />8b. UNTY
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<br />Nebraska
<br />Mail
<br />Gre(rts Island
<br />gd: STREET AND' MBER e. APT. NO.
<br />W. _ P CODE• . g 1.1
<br />4057 Manchester Road
<br />'
<br />1ga. MARITAL STAT,IIS AT TIMd OF DEATH Milrrkd Neva Married
<br />1gb-NaaiEDFBPOVSE�'(r¢t, Mdtils, tragi, stifnx)tlwHa,RlveltNllddg emote
<br />i
<br />❑ Married, but separated a Widowed �]: plvomed [].Unknown
<br />BarbMa Ann , `.i{1a11e
<br />11: FATHER'S4JAME (F1sk Middle, Last. Suffix)
<br />�12:`MOTNEWS-NAME (Fiti6f. Middle, Illsiden 8gmalriej ::,
<br />Frank Rakosky
<br />Freda Rphd9:
<br />,
<br />13. EVE IN U. FORCER? GUve dorsa of sepdce iiYes _ -
<br />168. INFORMAW-NAME.
<br />1411. RBA B"TO DECE T
<br />Vitt)
<br />Barbara Ann Rakosk :
<br />,�
<br />3B METHOD OP DISPOSITION
<br />..
<br />18s. EMBAIiMER 810NATU E
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<br />16b; UCENRQ:NO.1
<br />ISO. t pfl„�q Y.
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<br />[ja,"at Q°tmaden
<br />NotEtfMmed
<br />sept4rnbpr^M�i.} 5i
<br />®Cremation ❑ Elttombment
<br />• 7 F
<br />lid. CEMETERY, CAEMATORV OTHER LO CAM 4111 f TOYVN , GTAi* g ;
<br />Q Removai ❑ Odter (Iipectfy).•
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<br />CoMral'Nebraska Cremation' Services Gibbon s
<br />1. 8. FUNERAL NOME NAME AND MAILING A R 4 City of tate!
<br />s
<br />a
<br />All Faiths Funeral Home; 2629 S. Coost Street, Grand i Ibtld. Nebraska
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<br />DWHASeq n Of9! NEW)a
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<br />18.10A 1. ardertheahein,gLq,)ew4.«gsaaas„)njurlu, 00 ria4iut dGectlY ceetadtAa datth: DO NOT eraerlPdnhnd w0+aasaah •seardee egret, -; t ... i
<br />„,.
<br />. - roapireeryarreal. Pr vanvlaWar abnitWon allNeut showing the oHetogy. DO NOT ASSR111MYE: OvIiar oMy ane care@ so a Mae: Add admorpll IMsd If coomory.
<br />t IMMEDUATECAUSE: I etubtq ; .
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<br />h -
<br />Iagdt�ll'PECAUSE(Wnaf. a)D&T*NiB I -.':.
<br />dkieseeoreendlaenmaaina , .. .. IL ib "Al
<br />MI'de/� . t�aE.. QR (j1F: . ' 1t .. f+b •$J
<br />) _.. '_
<br />d i
<br />any, kedlneto.the couselifted - - ;• -.,r t d'. ( . S i •)
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<br />on fine A. i
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<br />DU TO,. AS A _ 1
<br />Rose am UNDERLYING CAUSE C) ., ,. �. - ` . , .'
<br />(disease or injury stat Ing
<br />•...
<br />the svelte recusing ki death) .DUE TO, 6R AR A CpNRE0i1$PICE OR:
<br />LAST -
<br />18. PART IL OTHER SIGNIFICANT CON77f ,IONa�CortdKlorts otsntrllttth+g to'thedea Dut sot lesul 9 in Ru 4nft lOn p*ise SWOo.Itt PAR
<br />OR Od110NER tVj...
<br />YW
<br />❑.l®'
<br />. IF FEMALE:
<br />2/e. M NNSR WRATH
<br />1b, IF TRANSPO tA_;5N INJU.
<br />21c, "AS AN :AU t
<br />' -
<br />p�
<br />❑ Not pregnant waMn pan year
<br />_� *-nm ', Q 61omkWe
<br />tNivor/t)pwator
<br />❑ YE$ '
<br />W
<br />tC}}
<br />Ptagnam st time a death � •
<br />❑.,
<br />AcsidaM ©PdniEng Ihvl4tiYattwi
<br />;; 04asaii®ee
<br />...®
<br />d:AW1tt AV
<br />TO C�APLETr!.CaNIsQR OE,ATl14';
<br />❑Not pragnadt, but pregreM wltialn 48 tl�a W death
<br />..
<br />SWcide Codla not be determined .
<br />❑
<br />©Mdestrion
<br />r
<br />.
<br />Not pregnant, but Pregnant 43 days to 1 year before death
<br />Unknown p pregnant within the past yead.
<br />.. I
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<br />❑ t et.(8,.. l
<br />% ' ...
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<br />,❑ YI:a ""'�, No
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<br />22a. DATE OF INJURY (Mor Day. Yr.)
<br />22b. TIME QF NtJURY
<br />22a PtAC OF N+LIURV,At Irotne.•farpi direst; , figs bdlPdlttS,.cEe=tiNcdoh, . qt, @tR
<br />9
<br />22d. INJURY AT WORK?
<br />DESCRIBE HOW INJURY OCCURRED
<br />i'
<br />(3 YES 0 N
<br />,
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN
<br />t�eptember
<br />OF DSATH (Ma, Day, Yr.)
<br />11, 2015
<br />:. r..
<br />2416 Dt0.TE' SIGNED 01b,, DelyrYr.) • 84i OP.
<br />�
<br />F3,ATE
<br />ATE SIGNED (Mo., Day. Yr.)
<br />e tember 14,2015
<br />23c. TIME OF DEATH
<br />06:30 PM
<br />- ieaOn ne blab.01ind i l .
<br />B tie Nme,.daw sid pi” sed due td tapas! seals. tPrk?Irel
<br />the beat of nW knowledge, death occurwi at de time, daft and place
<br />due to tiro cause(s) ended. (signature and Titre)
<br />t F
<br />Travis S. Hageman, MD
<br />OID TOBACCO URE CO BU TO THE DEATH? 26a. HA8 R O DONATION BEEN
<br />WAR CRAP► d
<br />b
<br />YES Q NO Q PiKMA13LY Q UNKNOWN YES NO
<br />Appkcabte lf*i li No' $ .'.
<br />37. NAMS, TITLE AND A00KEZ5 OF GrKTIPIRK pe or Fnntj
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a.RECiiSTRAR'SSIGNAT'URE
<br />DATM CEgBYREt3 _W'00 Yet
<br />September 18.2013,~
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