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<br />STATE OF NEBRASKA
<br />4felJitEFINaaas.: akv349RR , r t<�+j,9
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<br />AIR Not
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<br />THEN T IIS COPY CARRIES THE' RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA RIS
<br />COSY ©F THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, V1TAL.REOORDS.OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />4 DECEDE '$.. ME (Ffiet Middle
<br />•
<br />firs Ilftft W aekc iak
<br />d' CITY AND $'FATE R 1'ERRIT
<br />202208426
<br />01441/ 6,04-etza
<br />SARAH BOHNENKAMP 1,
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH'
<br />AND HUMAN SERVICES
<br />4 t lyfy*iSM,tei)1}J)V4;J (f!(UCe'A iii;.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE.OF..DEATH
<br />Last, . Suffix)
<br />Y, OR FOREIGN COUNTRY OF BIRTH
<br />O.maha)Nebrask•
<br />...:
<br />7 $QCIAt $ECt RIP(Nt MMER:
<br />50 0 $
<br />8b 'FACILLTY. NAME (Itnotlffstitutlon':give street and number)
<br />7t5. ie
<br />so CITY OR TOWN OF DEATH
<br />Grdnd 1A1afld B8&03'''
<br />9a: i' 2ESIDENcE.SI`ATE'
<br />NetaraSka.... '
<br />3 kTCEar:ANi 'NIM EI
<br />7 6 Jerry>Or,
<br />MARITALSTATN
<br />]'Married; t*ttsej
<br />*i40.R"3 AAiuio
<br />9b. COUNTY
<br />Hall
<br />OF PEiATtt.:® Married 0 Never Married
<br />led ❑ Divorced 0 Unknown
<br />43 EVER IN U ;ARMI
<br />(Yes ,No, or (Ink.) N
<br />?'Give dates of service if Yes.
<br />5a. AGE Last Birthday.
<br />(Yrs )
<br />8b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />3. DATEOF DEATH Fret):; Day Yr );;
<br />November 17, 2022
<br />• 6. DATE OF BIRTH'(Mo., Day, YP I '".
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL Q Inpatient
<br />0 ER/ou patient
<br />>0 D.QA..
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />HOURS
<br />MINS.
<br />May 14, 1 961
<br />OTHER ❑ Nursing Home/LTC..
<br />® Decedent's Home;:
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH.
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Oiwg itoc
<br />101i NAME OF SPOUSE (Firet Middle, Last, Suffix) If wife, give
<br />David Waskowiak
<br />14a. INFORMANT -NAME
<br />David Waskowiak
<br />18a. EMBALMER -SIGNATURE
<br />NotEmbalmed
<br />12 Mcenlgi 'S -NAME (First,
<br />Doraldine Snyder
<br />..................
<br />16d.:CEMETERY,.CREMATORY OR OTIfER LOCATION
<br />Central Nebraska Cremation Services.
<br />t1E ANC* MAILING ADDRESS (Street, City or Town, State)
<br />babel:8005..S.':Locust St:; Grand Island Nebraska
<br />.16b. LICENSE NO.
<br />Middle,
<br />CITY / TOWN
<br />Gibbon
<br />14b RELATI
<br />Spouse`
<br />16t. DATE(Mo;,;
<br />Nayember
<br />202:
<br />CAUSE OF DEATH (See instructions and examples)
<br />18:.0ART I, Entatthe atiain'of'eiietits- rAaeases, Enjuries, or complicetionsdhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />ieepiraloryarrest orveMti4.ular filirlllatlo'nwithout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If nec
<br />IM MEDIATE'CAUSE:
<br />Metastatic colon cancer
<br />.'111.daaa3
<br />soguentlagY.iist c
<br />eni r_FeadingJO tha:
<br />E TO, OR AS A COWSEQUENCE OF:
<br />DUE TO,:ORAS'A CONSEQUENCE OF:
<br />EnY r the`,t1NDERi. t .Nr3 CAti$E`
<br />:.lalsoa$@-Or injury.[iiid'iAi ,aE@d
<br />_th$'everits'r6sldting IC;deathl
<br />LAST.
<br />DUE TO,.OR ASS A CONSEQUENCE OF:
<br />1
<br />(0TH
<br />ER SI
<br />NII.IGANT CONDITIONS -C
<br />ditlons contributing to the:death
<br />shin pastyesr.
<br />t of deattt, ;:
<br />ut pregnant wit
<br />td pregnary't43
<br />ghant-.wld n 9i.
<br />42 -days of death
<br />•ra to 3 year before death
<br />OCADON'9
<br />21a. MANNER OF;DEATH
<br />Ea Natural ❑ Homicide
<br />0 Accident 0 Pending Investigatioi
<br />❑ Suicide 0 Could not be determined
<br />:'resulting in the uriderlying cause given In PART i.
<br />22b. TIME OF INJURY
<br />21b. IF::TRANSPORTATION INJURY
<br />0 Dnva (Operator
<br />Q Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />WAS MEttil
<br />OR;COItON
<br />❑ Yes
<br />21c., WAS AN AU
<br />0 YES
<br />21d WERE AUTOPSY FIN NGB AVAIiA
<br />• To,COMFLETE-CAUSE OF.DEATW?.
<br />❑YES -NLS°
<br />22c. PLACE OF INJURY At hotrle, farm, street, factory, office building, cons
<br />22a.:0ESCRIBEHOW INJURY OCCURRED
<br />« STREET & NUMBER, APT.NO.
<br />23a DATE OF.DEATH (Mo., Day, Yr.)
<br />November 1?, 2022:
<br />clrYrroWa
<br />23b :DATE Sit#NED (Mst,:Day, Yr,)
<br />Ngverlier''1'� .2022
<br />SSd,:To:t/xe beat ofmy itttowledge; death occurred at the time, date and place
<br />dtpstothle:ptiusa(s) stated )Signature and Title)
<br />23c. TIME OF DEATH
<br />05:20 AM
<br />tion' site, etc :tt
<br />S
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP WOE:
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNOED DEAD:..
<br />toe. pn the bots of examination and/or investiga Ion, bimy opinion deagt o.Gr.U,r
<br />tl;a drfie; date and place and due to the cause(sastated. (Sigr}ature fit. Thiel
<br />5: -Dip TOBACCO USE C:ONTRIBUTETO THE DEATH?
<br />YES ❑ NO [ PROBABLY ® UNKNOWN
<br />?�dAM , *TI EANg,e,R tESS O1; CERTIFIER (Type or Print
<br />•Chad U(ettt MD, 21161N Eardley #400, Box 9802, Grand Island, = 58803'::::
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E NO
<br />26b. WAS CONSENT' GRANTED?
<br />Not Applicable if 28a is NO YES
<br />❑N
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 22, 2022
<br />
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