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STATE OF EBRASKA
<br />d tz,; aTolln`'Illppsa'.--::`.'.:7Z„li'ltRdtso:,1,:;`:¢t:h4l'I:I�:Pf.N^PDge.>,�crrr,MO,�„secs,,::�'�%., gGi�tly1+1�1�1,1iHs:.:
<br />;NrHis COPY;CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELO
<br />BE A`'TRUE COP� :: OF THE ORIGINAL. RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />SERVICES, VITAL. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />AND'
<br />*AMR >10Ist,
<br />Kosi<irlif kl
<br />AMOR TERRITORY,
<br />IoupCity, Nebraskai'::,.
<br />i s aAL sacuit1TY NriMBEt
<br />5 738574
<br />2025021,9Z
<br />SARAH BOHNENIKAMP
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />, Last, Suffix)
<br />ON COUNTRY OF BIRTH
<br />bb. FACILITY -NAME (If not Institution, give street and number)
<br />.• Vete af$-Affairs;!'Aed:lcal.Center
<br />TV>OR TQWNfF DEATH
<br />t1e. RESIDENCE -STATE
<br />r :Nebraska
<br />>i STOOrri .0lUMBER
<br />is 903 W. l81l :S .1'IEt :":
<br />'Ilia 'MARITAL sTATUS AT`TIME OF DEATH ® Married D Never Married
<br />Zip Code)
<br />9b. COUNTY
<br />Hall
<br />art a •D Widowed 0 Divorced 0 Unknown
<br />ACHE (Flirt;•
<br />oSIi icki',>:::•.:
<br />M
<br />1e, Last, Suffix)
<br />ia, EYEII IN U.B. ARMED'VORCES? Give dates of service N Yes.
<br />962-04/13/1956
<br />(Ya No,, or Unk) Y i t?4/25t1
<br />15:'91ETNOD >F DISPQSI'flON.
<br />Crmfaon CtE,ISarsst
<br />Removal {,other (Specfy)
<br />170IJNERAl
<br />:<Cirran Furl
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />91;:
<br />6b. UNDER 1 YEAR
<br />MOS.
<br />sa. PLACE OF IBATH'
<br />HOSPITAL ®.inpatient OTHER 0 Nursing Homo/LTC
<br />❑ ERlOutpatlent 0 Decedent's Honig
<br />Q. DOA. _ / D Other (Sp y)
<br />18d. COUNTY OF DEATH
<br />DAYS
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3 DATE
<br />January,,
<br />6. DATE OF-
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Hall
<br />ire. APT. NO.
<br />f,
<br />9f. ZIP CODE
<br />68803
<br />July:14.,
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If calfe, give
<br />Norma Jean Wyl nd
<br />IL MOER'S-NAME (First, Middle, Malden
<br />Cashmiere.: Grudzinski
<br />14a. INFORMANT -NAME
<br />Norma Jean Kosmicki
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />ME AND MAILING ADDRESS (Street, City or Town, State)
<br />babel, 3005 S. Locust St., Grand Island, Nebraska
<br />18b:1,ICENSE NO.
<br />1.092
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See Instructions and exam Iles)
<br />dlaswes, *Juries, or complicedons.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />it, ory a art bi0lstlan rWdtout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a ripe. Add additional lines a necessary.
<br />IMMEDIATE CAUSE:
<br />Aspiration pneumonia
<br />AS A CONSEQUENCE OF:
<br />la
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C) Dementia
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />1:8. PiA4 '>:il : t? IFISR SIGNIFICANT CONDITIONS -Conditions contributing to the death but'r of rebultirig In tf e,ui denying cause given in PART I.
<br />Polymyalgia rl1E umet(Cii :
<br />days of death
<br />sto year before drat%
<br />21a. MANNER OF DEATH
<br />II Natural ❑ Homictd .::.
<br />❑ Accident ❑ Peni ing:inveetievece• •
<br />0 $tiicids ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b..IF'TRANSPORTATON INJURY
<br />Q�t Dfivw[ipemtor
<br />tom: ,
<br />© Pssesnaer
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />1
<br />"l
<br />21c. WAS AN
<br />DYES
<br />21d. WERE A
<br />TO C IMI
<br />Dom►
<br />22c. PLACE 'OF'INJURY-At horse, farm, street, factory, office building,
<br />5GAT1( OE':INJURV . SEREET & NUMBER, APT.NO. CITY/TOWN: STATE
<br />2"k► DA IE OF DEATH (Mo , Day, Yr-)
<br />January 31, 2025 _ ' .
<br />23b.DATE;SIGNED..; o:, Vr.) 23c. TIME OF DEATH
<br />.:.0 ' a P
<br />;::To ' : bsstot:my'tAowlsdge, death occurred et the time, date and place
<br />duli:lo t s ciluee(s) staNd. (SHgmlturs and mis)
<br />Jennifer King, MD
<br />TL A CCO USE:COI TRIBUTE TO THE DEATH?
<br />Q'.plitlEABLY El UNKNOWN
<br />24a. DATE' SIGNED (Mo., Day, Yr.)
<br />249. PRONOUNCED DEAD (Mo., Day, Yr.) 24d.
<br />26a. HAS ORGANOR71SSUE DONAIif;TN B NCONSIDERED?
<br />DIES 1 NO
<br />ADDRESS OF cER1 R (Typo or Print . .
<br />Vff , 2 11 N iiroadwell Ave, Grand Island, Nebraska, 68803
<br />20b. WAS CONSFNI'
<br />Not Applicable If 26s is
<br />26b. DATEFILED BY RSOq
<br />February 7, 2025
<br />
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