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<br />-0 SpTxA�11dA0n�n�TE_OF NEBRASKA
<br />tRff.,),Itr._.. .._ .......... t1onyax{OI3f. Ltrr,r,1/1 jpiez.' arfn 35 ........
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<br />COPY:CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />COPY 'OF`THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />i ATE`OF7SSUANOE
<br />8/30/2024
<br />G.OLN,:.htE'BRASICA
<br />202405285
<br />&1t4.144t-
<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 />RTIFICATE OF DEATH.
<br />CERTI
<br />Middle, Last, Suffix)
<br />k)itl ` MjelIae : •Krelikowski
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />L.ciiap'Gsty, Nebresks::;
<br />i 1A1 SECV(itTY NUd119ER
<br />2-2369'
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />eb. FACILITY -NAME (If not Institution, give street and number)
<br />;<Cl-I) iealtlt;> t.;Frarldils
<br />#1 Y O,R;TOWN=Ckt DEATH (Include Zip Code)
<br />Grafid'tsian 6880
<br />9a.fRESIDENCE-STATE `)
<br />1
<br />rk1EET:At4 7.rtUNfdt R ;..
<br />09 N::Ha cock:Ave
<br />9b.000NTY
<br />Hall
<br />104, MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />0 .Married but sepilrated ❑ Widowed ❑ Divorced 0 Unknown
<br />FATHER`6-NA E;iFrst,; :: Middle, Last, Suffix)
<br />Lenard .leratik+awskl
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 09/18/1962-09/17/1968
<br />&' fn;ETI'tOD OP DISPOSITI N
<br />_v1S trial ;::':;; ` Donation
<br />ret#iittlor > Enttrnlmettt
<br />0 Removal ❑ Other (Specify)
<br />79.
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />Ea ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />.2411.
<br />3. DATE OF DEAT#:I.fMo.,
<br />Aupu0 18,.?O24
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />IIOf:I .: l
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden hate
<br />Sheila :..Stobbe
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Luella . Jakubowski
<br />14a. INFORMANT -NAME
<br />Sheila Krolikowski
<br />1Sa. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />170. FUNERAL MDI S NA.MS. AND MA LING ADDRESS (Street, City or Town, State)
<br />All. Faiths Fu':ner i' Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />Is. PART I. triennia chain of events. -diseaess, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />retipitehay arrest;or viYntl'leu.er fibrillation without showing the etiology. DO NOT ABBREVIATE,.. Enter only one Cause on a: tine. Add additional lines if necessary.
<br />i^tIMMEDIATE CAUSE:
<br />JMMEDIATE;C USEIF*na1>(:.'[:> a) pneumonia
<br />dissesti'itecoiidxiOn y,suShip .
<br />hj DUE TO, OR AS A CONSEQUENCE OF:
<br />__..,ustiustly;gst conditiotfe, L::. b)
<br />ya te. tea(1kt{itA;ttle;t.):iuee'FiEPS&
<br />.4j444
<br />'DOE TO, OR AS A CONSEQUENCE OF:
<br />UNDERLYING CAtj E C)
<br />A 1dNease or injury that Initiated
<br />the events resulting in a
<br />'.:'te. PART ti OTH
<br />emphysema
<br />7s IF:l Ma S:
<br />�'*� Not pnpifunt whin plat y iiir
<br />earranliit time: bf dslt}t
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />of pregnant, rite ptegrlant 43 days to I year before death
<br />4# kno nlrptegttantwitliin the past year
<br />SIGM
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />•D)
<br />ANT CONDITIONS -Conditions contributing to thi death but not resulting in the underlying cause given in PART I.
<br />22a. UATE' 1 VJiURY:;{Mo F;
<br />t..
<br />JRY AT WORK?
<br />1'YES < INQ:;;.:"">'
<br />y, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />210: IF TRANSPORTATION INJURY
<br />0 Driv rlOperator
<br />. ❑ /Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP TO
<br />Spouse
<br />16c. DATE (MO
<br />August 274024
<br />STATE
<br />1
<br />APPRO,XIMATEINTERV.AL
<br />onset tdtilh.;'
<br />DIIIVS
<br />onset to'
<br />onset
<br />21c. WAS AN AUTOPSY PEi
<br />❑ YES ®Nit'
<br />21d. WERE AUTOPSY FINDING$ AVAILA5LE
<br />TO COMPLETE CAUSE r . DEATtl,7
<br />YES
<br />22c. PLACE: OF INJURY -At home, farm, street, factory, office building, construction silts e
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />JURY STREET & NUMBER, APT. NO. CITY/TOWN
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />August 18, 2024
<br />ATESIt;NEt34Mo., Day, Yr.) 23c. TIME OF DEATH
<br />>'A t u < 0. 024 05.27 PM
<br />T .._._,..,i ... :..
<br />3tI:::Tq iti►►:i[etY:tit»jy:knowletlge, death occurred at the time, date and place
<br />anr$ d4. to the reusels) stated. (Signature and Tine)
<br />Travis S. Hagoman, MD
<br />1)(.0104. c,geag oNt5(BU`rE TO THE DEATH?
<br />PROBABLY 0 UNKNOWN
<br />NAME; 1'rt1E41AD AtiORi'SS OF CERTIFIER (Type or Print
<br />Travis S. Hagerman, MD, 729 North Custer Avenue, Grand Island,
<br />,R GISTRAR'8..S1GNATU,RE
<br />g
<br />8 .
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUI
<br />tee. On the basis of examination and/or Investigation, In my opinion
<br />the time, date and place and due to the cause(s) stated. (alghature
<br />26a. HAS ORGAN OR TISSUE DONATION
<br />DYES 7 NO
<br />N CONSIDERED?
<br />J0044Wiiii
<br />26b. WAS CONSENT GRAN EDT.
<br />Not Applicable if 25a is NO
<br />28b. DATE FILED BY RECIHiTRAR (!
<br />August 26, 2024
<br />c
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