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4.1.5- IIVMt' ArlrN.M.. B41r11dio?..!TAW:"
<br />WHEN > T iS
<br />COPY CARRIES THE RAISED SEAL OF TH '•STATE OF NEBRASKA, IT
<br />;CERTIRES THE • DOCUMENT BELOW TO BE 4 TRUE COPY' OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS QFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL. RECORDS
<br />DATE OF'ISSUANCE
<br />11/16/2017
<br />rEBR4.:SKA
<br />202402501
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH tkND HUMAN SERVICES
<br />CERTIFICATE OF DEATH'
<br />DECEDENT'S -NAME (Fiat, Midde, Last, Suffix)
<br />Randy Daniel Krollkowski
<br />OrrY;.A ID STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand (Stand Nebraska
<br />T. SOCIAL SECURITY NUMBER
<br />508.-96-7555. ..
<br />FAOfi.1TY NAME (lf trot lnstltution, give street and number)
<br />Cl1i Health Nebraska Heart
<br />5a. AGE:- Last Birthday
<br />T(Yea)
<br />)
<br />48
<br />9h. UNDER..1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOs,
<br />8a. PLACE OF DEATH
<br />HOSPITAL Zi Inpatient
<br />Elfeufpitlent
<br />❑ DOA
<br />AYE
<br />HOURS
<br />MINS.
<br />3. DATE OF
<br />.,Day,Yr.).
<br />November6,20.17
<br />Yr
<br />OTHER 0 Nursing Home/LTC ltos ice Facility
<br />❑ Decedent's Home
<br />❑ Other (Speyity)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />.... Lincoln 68526 :....
<br />RESIDENCE -STATE
<br />Nebraska ......:.::
<br />9b. COUNTY
<br />Hall
<br />IC CITY:'ORTOYYN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />Oci.stnter ANt3NUMBER
<br />2808 Stagecoach P1.
<br />Ga MARITAL ST:ATUSAT TIME OF DEATH ® Married 0 Never Married
<br />Minted, btutsenarated!€: 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHERS -NAME (First, Middle, Last, Suffix)
<br />Roger Daniel Krolikowski
<br />3, EVERIN U S. ARMEDFORCES? Give dates of service if Yes.
<br />(Ye1t; No, Cr (Pk) No
<br />S. METHOD:OF:DISPIIIIITION
<br />®'8itdta) Donation
<br />0 Cremation 0 Entombment
<br />❑ keredyel Z otneri(Specify)
<br />9e. APT. NO.
<br />ZIP CODE
<br />68801
<br />'INSIDE CI1'Y:LI(NI
<br />®vas 0 NO
<br />Ob. NAME OF SPOUSE (Phar Middle, Last, Suffix) If wife, give maiden name!.
<br />Mercy Renee Trasper
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Margaret Ruth George
<br />14a. INFORMANT -NAME
<br />. .
<br />Marcy Renee Kro lkowskl
<br />16a. EMBALMER -SIGNATURE
<br />Marshall J. Buch
<br />•1eb LICENSE NO.
<br />1473
<br />14b. RELATION$IIP.TO
<br />Wife
<br />1Sc. DATE (MO., D1Y Yr.) :
<br />November 10, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />Ts FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funerai'Home. 2929 S. Locust Street. Grand Island. `Nebraska'
<br />PART:l
<br />CAUSE OF DEATH (See instruction
<br />and examples)
<br />- -disuses, injuries, or complications -that directly caused the -death. DO NOT enter forrpihal events such as cardiac arrest,
<br />•orvbrnittuler fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter onlyens cause on a hne; Add additional lines If necessary.
<br />ardMEDIATE CAUSE (Final
<br />dluase or condition resulting
<br />Sec0.00•tisily list edm ueae, d
<br />any teedulg to ttte:ciause listei .
<br />Enter the UNDERLYING CAUSE
<br />1iieslsti::Oe 11 ytry::tl5IN Ml4idted::::.
<br />the eventstMsdltiP94t ON* DUE TO, ORAS A CONSEQUENCE OF:
<br />d)Morbid Obesity
<br />IMMEDIATE CAUSE:
<br />a)Pulseless Electrical Activity
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Coronary Artery Bypass Surgery
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Coronary Artery Disease
<br />STATE
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />APPROXIMATE iN'.
<br />onset tO+leelili
<br />3 Hours
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES a.NO
<br />20 IF:`FEMALE
<br />otett prsghtf(wltlui pestyoar
<br />U1
<br />0 Pregnsnt st time of death
<br />ti pggrtani, but pregnant wlthin 42 days of death
<br />laytt Pegnartti; pia Pregiiio$13 days to 1 year before death
<br />❑. J»knoyut I.' pregnant ydtitlif.a a past year
<br />22a. DATE OF INJURY (Mo.,
<br />y, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending investigation
<br />❑ Suicide 0 Could not be WHennined
<br />22b. TIME OF INJURY
<br />21d tF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />p Drly r/Opet.ter ❑
<br />vas 56 ND
<br />0 Passenger
<br />❑pedestrian
<br />❑ Other(Specify)
<br />21d. WERE AUTOPSYFINDING8
<br />TO COMPLETE CAMSE OF *MORI?
<br />❑ YES 0 Ni
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, constru
<br />229. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN
<br />239 DATE OF DEATH (Mo., Day, Yr.)
<br />Novertlbert 2017
<br />236 DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />November 7.2017 09:57 AM
<br />4a GATE SIGNED (Mo., Day, Yr.)
<br />To the bast of my knowledge, death occurred at the time, date and place v
<br />ii and due to the cousins) stated. (Signature and Tide) E
<br />i4491.1100.H Wudel, MD
<br />26 OIt7 TOBACCti1JSE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE ONAT1ON BEEN>CONSIDERED?
<br />[} YES NO ❑ PROBABLY ® UNKNOWN ® YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />James H..Wudel,» MD, 7440 S 91st St, Lincoln, Nebraska, 68526
<br />c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24e. On the basis of examination endlor Investigation, In my apkdoe death ccW(ad et.
<br />the time, date and place and due to the camels) sitd.(eigrraire and hue)
<br />26b. WAS CONSENT GRANTEE?
<br />Not Applicable H 26a is NO . CI YES
<br />. DATE FILED BY i EGIS1
<br />November 13, 2017
<br />
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