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Rev 11,97
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<br />STATE OF NEEIPASKA- DEPARTMENT OF HEALTH AND FIUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH 2 0 011213 2
<br />1 rv1 tH UNLY VNt VAVSt YtH LINt vUH M 10). ANU ICI( + rraarver aetween one. $ -wam
<br />PART t
<br />Its, Cardic- respiratory Arrest Immediate
<br />IN Severe cardiovascular disease with ischemia
<br />DUE TO OR AS A CONSEQUENCE OF
<br />I Interval be%~ On NI are deem
<br />I
<br />10 Years
<br />I keerVal bet. onset and thee+
<br />I
<br />Icl
<br />O1 HER SIGNIFICANT CONDITIONS - Condlticns conlriMAinp to the death btd not related PART
<br />1 DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />B DATE OF DEATH /Mona+ DeY Yowl
<br />PART C infarction previous l ,RECNANCV
<br />I1+, myocardial
<br />Edward John Sten]ca
<br />Male
<br />June 11, 1998
<br />A CITY AND STATE OF BIRTH /and in USA nema tounnyl
<br />So AGE - Last Bir dsy
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />B DATE OF BIRTH /Mbnp. Oat, ✓w /
<br />51, MOS I DAYS
<br />SC. HOURS' MINIS
<br />Sherman County, Nebraska
<br />(Yrsl 80
<br />October 1, 1917
<br />October
<br />7 SOCIAL SECURTIY NUMBER
<br />Ba PLACE OF DEATH
<br />�
<br />508 -12— 05 6 1
<br />J V 1
<br />HOSPITAL ❑ InoaasM OTHER_ Nurse+q Home
<br />—
<br />w
<br />❑ ER OtapstleM ❑ Mlldance
<br />Bb FACILITY - Name IN nor— wrion, Diva Fneat find number/
<br />Grand Island Veterans home
<br />❑ DOA ❑ Oaar ISPecMI
<br />BC CITY TOWN OR LOCATION OF DEATH
<br />Bd IN$IOE CITY LIMITS
<br />8e COUNTY OF DEATH
<br />Grand Island
<br />yes [� No ❑
<br />Hall County
<br />27A DAIS OF DEATH /Md Dev yl
<br />9a RESIDENCE - STATE
<br />9b COUNTY
<br />9c CITY, TOWN OR LOCATION
<br />9d STREETANDNUMBER /hch.elYp Zb LerMl
<br />INS
<br />M IN90E CITY LIMIT
<br />yy,,
<br />A,
<br />Nebraska
<br />Hall
<br />Grand Island 11614
<br />N. Cedar 68801
<br />® No ❑
<br />29d. PRONOUNCED DEAD &A%#1
<br />10 RACE le 9, While Black AmeritaA Indian
<br />11. ANCESTRY Ie q Italian. Marken, German, eltl
<br />12. ErARRIED O WIDOWED
<br />12 NAME OF SPOUSE /Mw* "mebYn lame)
<br />2 :00 A. M
<br />etc I ISoecityl White
<br />ISnac`Y olish
<br />I
<br />MASEVED 1
<br />NEVER DIVRVrytsr*ca*TeryI0-I2j
<br />Wanda Lubash
<br />e
<br />I
<br />14a USUALOCCUPATION IGrve kind of+ * oU+e oUrinp meal
<br />KIND OF BUSINESS INDUSTRY
<br />ATION ISpecAy only hlpMMpredecodgtetedl
<br />A
<br />d adbrg kb. ease a v"edl
<br />Farmer
<br />114b
<br />Agriculture
<br />C~ 11 e a S • I
<br />as hme, date and pate and dua b tM talselsl ateled.
<br />16 FATHER -NAME FIRST MIDDLE LAST
<br />t7 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />I
<br />Frank NMN Stenka
<br />I
<br />Gertrude NMN Shuda
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />18 WAS DECEASED EVER IN US ARMED FORCES?
<br />19e INFORMANT -NAME
<br />❑ YES ® NO
<br />(yea no a ..it I IB yes VYe war and date$ d so cool
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEYI I7vya a Phil
<br />M.A. Tompkins, M.D., Grand Island Veterans Fume, Grand Island, NE 68803
<br />Yes Ol 10 -42 to 12 -19 -45
<br />Wanda Stenka
<br />I9h INFORMANT MAILING ADDRESS ISTRFET OR R F O NO.. CITY OR TOWN. STATE ZIP)
<br />1614 N. Cedar, Grand Island, Ne. 68801
<br />20 FM .M R - SIGN E A LI E NO. �/
<br />n �//
<br />2/s MFTHODOF UISPOSITtON
<br />21b DATE 21e
<br />CFMETERY OR CREMATORV NAME
<br />�Pu.Iel ❑RemoYal
<br />June 13, 1998
<br />Westlawn Memorial Park
<br />22. NERAL AME CIZ,
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sondermann F.H.
<br />❑Cremation 1:1Donal'on
<br />Grand Island, Nebraska
<br />221, FUNERAL HOME ADDRESS (STREET OR R. F.0 NO CITY OR TOWN STATE, ZIPI
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />1 rv1 tH UNLY VNt VAVSt YtH LINt vUH M 10). ANU ICI( + rraarver aetween one. $ -wam
<br />PART t
<br />Its, Cardic- respiratory Arrest Immediate
<br />IN Severe cardiovascular disease with ischemia
<br />DUE TO OR AS A CONSEQUENCE OF
<br />I Interval be%~ On NI are deem
<br />I
<br />10 Years
<br />I keerVal bet. onset and thee+
<br />I
<br />Icl
<br />O1 HER SIGNIFICANT CONDITIONS - Condlticns conlriMAinp to the death btd not related PART
<br />III IF FEMALE, WAS IHERE A
<br />AUTOPSY
<br />1
<br />28 WAS CASE REFERRED 10 MEDICAL
<br />PART C infarction previous l ,RECNANCV
<br />I1+, myocardial
<br />IN THE PAST 3 MONTHS?
<br />121
<br />E %AMINER OR CORONER?
<br />diabetes mellitus. COPD dementia.
<br />(Ages t0 -541 Yes Nd
<br />Yes n No
<br />Yee No Rk
<br />26a
<br />26b DAIE OF INJURY /Ma Day W1
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Arcldent F] LIMM..mined
<br />1
<br />M
<br />U Smcde [:] Pendinb
<br />26e INJURY AT WORK
<br />261. PLACE OF INJURY - AI Ti term. sbaN IMWV
<br />269. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE
<br />OHnm+tvte Inve0gahon
<br />Yes ❑ No ❑
<br />n ce n n9. ale lSpee.
<br />27A DAIS OF DEATH /Md Dev yl
<br />280 DATE SIGNED /Mo Do, ✓rl
<br />281, TIME OF DEATH
<br />s
<br />June 11 1998
<br />yy,,
<br />A,
<br />M
<br />27b PATF SIGNED IM, Dav v.1
<br />27, TIME OF DEATH
<br />26c PRONOUNCED DEAD /Me Day. Yrl
<br />29d. PRONOUNCED DEAD &A%#1
<br />June 11, 1998
<br />2 :00 A. M
<br />i
<br />M
<br />e
<br />I
<br />27A In pro Met M my knnwleA9e Mam otturrM b H+a dme, data Ann der$ and due a d+a
<br />2Be On e» basis of eaammseor+ Ara a ewaelpAron. In rrry opmon death oeeared at ,
<br />P
<br />A
<br />"ZI'l Slated 'f
<br />A
<br />as hme, date and pate and dua b tM talselsl ateled.
<br />S we and Tills
<br />I
<br />ISOo1Uro led Tillol No
<br />20 1111`1 TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES ❑ NO X UNKNOWN
<br />❑ YES ® NO
<br />1:1 YES ® NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEYI I7vya a Phil
<br />M.A. Tompkins, M.D., Grand Island Veterans Fume, Grand Island, NE 68803
<br />Vo REGISTRAR
<br />32b DATE FILED BY REGISTRAR (W. Dry. Y j
<br />FOR VITAL STATISTICS USE ONLY
<br />hereby certify this to be a true and correct copy of the original
<br />filed with the State of Nebraska
<br />by
<br />S;F, ned in my presen s 422 day of 22=' cW04
<br />P Notary Public
<br />v
<br />NOTARY -'Slate of e,
<br />III TERRY L. LOSCHENI�G
<br />MY Conlin. Exp.
<br />
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