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STATE OF NEBRASKA
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<br />WH£N i; HIS 1410-14-R IES THE RAISED SEAL OF STATE OF IIIEBRASK: IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF'THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN 5ERWC• ES, V)TAL RECORDS OFFICE, WHICH IS THE LEGAL REPO: STORY FOR VITAL RECORDS
<br />DATE OF. ISSUANCE
<br />........... ...... .....
<br />....... ...... ....... .......
<br />............... ....... .......
<br />3/11 /2024'
<br />LINCOLN, NEBRASKA
<br />3
<br />20240105$
<br />SARAH BOH' ENKA
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1.1DECEDENT9 NAME: (First, Middle, Last, Suffix)
<br />Thtllresa< Anne Urbanski
<br />CERTIFICATE OF DEATH
<br />4: CITY AND: STATE OR 1 ERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Palm City, California
<br />7 SOCIAL aecunrrY NUMBER
<br />50842-9732
<br />86:. FAICIIJTY AM1? (if not Institution, give street and number)
<br />1824 Grand Island Ave
<br />Sc ;CITY OR'TOWN.OF EATH (Include Zip Coda)
<br />Grand tstelnd 68803
<br />9a RitioakCE-StAtE
<br />Nebraska
<br />9d :STREETAND NUMBER
<br />1824;Grand Island Ave
<br />9b. COUNTY
<br />Hall
<br />Si,AGE Lsal;Birtttday
<br />(Yrs.)
<br />69:..
<br />8b, JNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a'PIJ►CE OF DEATH
<br />HOSPITAL: L.JInpatfent
<br />❑ ER/Outpatient
<br />❑ DOA
<br />10* MAttITAI: STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated C Widowed Q Divorced 0 Unknown
<br />11.FATNER'S.NAME (First, Middle, Last, Suffix)
<br />JOseDh'Shafer:i::<
<br />13.::EVER IN LLS. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />18. METHOD OF DISPOSITION
<br />Buttal 004:00on
<br />CremtW Bit [, Entoittbment
<br />Q RemovaA Ia Otl»r (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />r,
<br />24 02718
<br />3. DATE OF Oca'Al.g011ION1i.4.1%)01n
<br />Found February
<br />8. DATE OF Bi(4":t'(1(Mo ; Dary, Yr.) ::
<br />September 8....:1:954:........
<br />OTHER 0 Nursing Home/LTC
<br />El Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />1Ob. NAME.: OF SPOUSE (First, i MI
<br />Thomas Urbanski
<br />14a INFORMANT -NAME
<br />Thomas Urbanski
<br />18a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />91. ZIP CODE
<br />68803
<br />e, Last, Suffix) If wife, give maiden name`
<br />12. MOTHERS -NAME (First, Middle, Malden Surname
<br />,Josephine:: Hindmarsh
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a.FU.NERALHoles .NAME AND MA UNG ADDRESS (Street, City or Town. State)
<br />All FaithsFuneralHome, 2929 S. Locust Street. Grand Island,. Nebraska
<br />18b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (t3 ie>i ietrt etlokili:;3ind examples)
<br />10. PART I. Entirthe chain of event*. diseases, Injuries, or complications -that directly cawed the death. DO NOT anter teiminal events such as cardiac arrest,
<br />respiratory aunt, or ventricular fbrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />• IMMEDIATE CAUSE:
<br />as IRDIA'tac*vse(del a) Myocardial Infarction
<br />disuse of o d(Non rewMing
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially tat conditions, If b)
<br />any, !gliding to the cause listed
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />t Iflht i ld C)
<br />i Ill shat:inntNed
<br />IflttK the UN
<br />(dNeti+gtt o'r
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />IA$T d)
<br />IS PART'IL OTHEEt SIGNIFICANT CONDmoNS-Conditions contributing to the death bu
<br />20. IF FEMALE:
<br />kili:#4.SfegbeitperiEN4PSetrar
<br />O PragltantattindOtiiestki
<br />Q Not pngmun bur: pregnant wltha 42 day* of death
<br />0 Not pregnant, but pregnant 42 days tot year before death
<br />r-� UnknoantN pregnent within the past year
<br />22t DA
<br />OF INJURYYr.)
<br />22d. INJURY AT WORK?
<br />Q YES ©NO
<br />21a. MANNER:OF DEATH
<br />Natural Ho hiplde
<br />El Accident Ppinling ihv}stipation
<br />Suicide ❑ Ceuld not be determined
<br />22b. TIME OF INJURY
<br />22c. FLA
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221 :LOCATION OF INJURY, STREET & NUMBER, APT.NO.
<br />ii.....
<br />J
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />°Pam
<br />CITY)TO • N
<br />23c. TIME OF DEATH
<br />a `� tdd.'Ii)1M i ect of lily knowledge, death occurred at the tine, date and pad _
<br />nett due Int pews(*) stated. (Signature and Title)
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />© YES 3© Nti rQ PROBABLY ® UNKNOWN
<br />2Y NAM;F„ iTIT(J AND I1DDRESe OF CERTIFIER (Type or Print
<br />'MatthewAdan VStorks, Deputy Hall County Attorney, 231 South Locu$tStreet' Grail island, Nebraska, 68801
<br />tl
<br />mein the underlying cause given M PART I.
<br />21p. IF TRANSPORTATION INJURY
<br />1 D.ilvar/Operator
<br />rl Pnlisenger
<br />Pasestrisn
<br />0 Other (Specify)
<br />itDEtr"f'Clr UMrrs
<br />Yes O; NO'.
<br />t4b. RELATIONSHIP I'O D DENT
<br />Spouse
<br />180. DATE Mo., Day, Yr.):..:
<br />February?:
<br />Nebraska
<br />68801 .
<br />APPROXIMATE INTERVAL
<br />OnsetEto dealt
<br />Imtrledtate
<br />onset ha 'death
<br />one* Ito death
<br />!A' WAS MED(+ AL EilAMINE 2
<br />OR COR�C�t' t R CON b?';
<br />® YES ❑ NO
<br />21c. WAS AN AUTOPSY pERFORNIBp
<br />❑ YES
<br />21d. WERE AUTOPSV FINDINGS A AtIABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />Q YES ( ;.NO.::.,.
<br />some, farm Street, factory, office building, construction alts«?.
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />February 23, 2024
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />Februarv,22.2024 Alts
<br />24e On the basis of examination and/or Invaetgation, In my opinion dgill GEt urs
<br />ate time, date and place and due to the cause(*) stated. (Signature h id `:TRS)
<br />Matthew Alan Works, Deputy Hall County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION; BEEN CONSIDERED?
<br />0 YES fil NO
<br />24b. TIME OF DSATN'
<br />Approx. 03:00 AM
<br />-24d. TIME PRONOUNCED DEAD
<br />08:58 •
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable N 211a Is NO 0 Yts
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 28, 2024
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