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WHEN TM COPY CARRIES TI# RAISED SEAL OF THE NEBRASKA HEALTH AND HL4WAAN_-AE WCES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REkFI THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/ - THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE -' A_7 ._ OPT MAY 2 81998 200112678 ass1si`�rarE RE6 LINCOLN, NEBRASKA HEALTH AND HLAWN �VIVSES STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE.RVIM ERbOM E IPPOST VITAL STATISTICS CF.RTIFIrATF OF DEATH 1 DECEDENT -NAME FIRST MIDDLE LAST M M D Male I may 11 1998 d. CITY AND STATE OF BIRTH of not in US. A.. name country) a. AGE - Last Birthday ,.rn .�. UNDER 1 DAY �+ G era Cn o 5c, HOURS MINS 57 S D Au t 28 1940 7 O249flT,YCNU0.1BE0Rrado Be . PLACE OF DEATH F -+ p —1 p !�D Bb. FACILITY -Name /ft not rnstiNtron, give street and number) p El DOA El 8c CITY TOWN OR LOCATION OF DEATH Bid INSIDE CITY LIMITS 8e COUNTY OF DEATH � C D N Z= !m'f 2 9e INSIDE CITY LIMITS Nebraska Hall n m c-�� M. O am 13 NAME OF SPOUSE (/I wde or- maiden name) etc .I (Specityl White ISpec-tyl =D DIVORCED Lorraine Gawryeh 14a USUAL OCCUPATION /Give kind of work done during most 5 1 O db. KIND OF BUSINESS INDUSTRY (^x� /,�.k 9� 15. EDUCATION (Specity only highest grade completed) Elementary or Secondary 10 -12) College 11 4 or 5 -I p ~' O *7 O Six 16 FATHER NAME FIRST MIDDLE LAST 17 FIRST MIDDLE MAIDEN SURNAME M(DecOTHER' Alice NMI UNK _ - -- l.r 19a IN - NAME lVes no or unk l I of ves give war ar $ dales of seroces) Korean I vt-q 11 -12-58- 05105170 V4 -- IjA Tnrraine Ferguson 196 ! NFORMANT MAILING ADDRESSSTREET OR R.FD NO.. CITY OR TOWN. STATE. ZIP) 107--East 21st Street, Grand Island Nebraska 68801_ 20 EMBA ER, SIGNATURE 5 LICENSPNO� 21a METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATOR, NAME CID v z ®Ronal ❑Removal May 15 1998 Westlawn Memorial Park Ce_m_E 22a FUNEFl L HOME NAM 21d CEMETERY OR CREMATORY LOCAI ION CITY OR TOWN STATE Kleine Funeral Home M 3 22b FUNERAL HOME ADDRESS (STREET OR FIT D NO CITY OR TOWN. STATE. ZIP) 3213 W. North Front St. Grand Island, Nebraska 68803 IMMEDIATE CAUSE IENTEA LLY ONE Mgt,, LINE FOR la). (b). AND (c)I Interval between onset an/d /� /�gearn PART "�1 DUE TO, OR AS A CONSEOUENCk OF Interval between onset and deatr. DUE TO, OR AS A CONSEQUENCE OF Interval between onset and dean o Idl I r x• N CD REFER y AS CASE RED TO MEDICAL PART PREGNANCY II IN THE PAST 3 MONTHS' cn N O Ves No 26a Accident Undelermmen 261b DATE OF INJURY /Mo.. Day. Y[) IF 26C HOUR OF INJURY M 26d. DESCRIBE HOW INJURY OCCURRED Swede Pending 26' a IN,IIIRV AT WORK 26i PLACE QF INJURY -At home. farm, street. factory o ice bonding, etc (Specify) 26g. LOCATION STREET OR R D NO CITY OR TOWN STAFF ❑Homicide investigation tle investigation Yes[—] No ❑ 7 DATE OF DEATH /Mo Day YrI 28a DATE SIGNED (Me Day Yrl O 5/11/98 O 5/20/98 11:08 a.m. M i ° 7 DATE SIGN l D GJ co C ♦MO' `(Yr;I �0 g M d To the bet of my knowledge. oc urred al he ti me. date tl D ace and due to the 28e. On the basis of examination and or investigation, m my opinion death occurred at - ° a ° causelsl stated ° the time, date and place and due to the causelsl stated. lS� nature and Title) ► IS nature and Tile ► .DID TOBACCO USE CONTRIBUTE TO TH DEATH? HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30 AS CONSENT GRANTED' L WHEN TM COPY CARRIES TI# RAISED SEAL OF THE NEBRASKA HEALTH AND HL4WAAN_-AE WCES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REkFI THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/ - THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE -' A_7 ._ OPT MAY 2 81998 200112678 ass1si`�rarE RE6 LINCOLN, NEBRASKA HEALTH AND HLAWN �VIVSES STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE.RVIM ERbOM E IPPOST VITAL STATISTICS CF.RTIFIrATF OF DEATH 1 DECEDENT -NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH (Momh. Day Year) Male I may 11 1998 d. CITY AND STATE OF BIRTH of not in US. A.. name country) a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Mont. Day Yeaq (Yrst 5b MOS 1 DAYS 5c, HOURS MINS 57 Au t 28 1940 7 O249flT,YCNU0.1BE0Rrado Be . PLACE OF DEATH HOSPITAL N Inpatient OTHER ❑ Nursing Home . 524 -42 -9229 - ❑ ER Outpatient ❑ Residence Bb. FACILITY -Name /ft not rnstiNtron, give street and number) St. Francis Medical Center St. El DOA El 8c CITY TOWN OR LOCATION OF DEATH Bid INSIDE CITY LIMITS 8e COUNTY OF DEATH VrOI A.I /$land Yes E No F1 Hall 9a RESIDENCE - STATE 9b COUNPA 9c. CITY. STREET AND NUMBFA.. /InckMirp.jrp 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 7107 E. 21st St. 68801 Yes No 10 RACE - (e.g., White. Black. American Indian, 11. ANCESTRY le .g Italian. Mexican. German, elcl ' O 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE (/I wde or- maiden name) etc .I (Specityl White ISpec-tyl =D DIVORCED Lorraine Gawryeh 14a USUAL OCCUPATION /Give kind of work done during most 5 1 O db. KIND OF BUSINESS INDUSTRY (^x� /,�.k 9� 15. EDUCATION (Specity only highest grade completed) Elementary or Secondary 10 -12) College 11 4 or 5 -I of working life. even it retvedl v Field Service Engineer En ineerin U 2 Years 16 FATHER NAME FIRST MIDDLE LAST 17 FIRST MIDDLE MAIDEN SURNAME M(DecOTHER' Alice NMI UNK _ - -- 18 WA DECEA E EVER ,N U S MED FORCES? 19a IN - NAME lVes no or unk l I of ves give war ar $ dales of seroces) Korean I vt-q 11 -12-58- 05105170 V4 -- IjA Tnrraine Ferguson 196 ! NFORMANT MAILING ADDRESSSTREET OR R.FD NO.. CITY OR TOWN. STATE. ZIP) 107--East 21st Street, Grand Island Nebraska 68801_ 20 EMBA ER, SIGNATURE 5 LICENSPNO� 21a METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATOR, NAME v z ®Ronal ❑Removal May 15 1998 Westlawn Memorial Park Ce_m_E 22a FUNEFl L HOME NAM 21d CEMETERY OR CREMATORY LOCAI ION CITY OR TOWN STATE Kleine Funeral Home ❑ Cremation ❑ Donmi., Grand Island Nebraska 22b FUNERAL HOME ADDRESS (STREET OR FIT D NO CITY OR TOWN. STATE. ZIP) 3213 W. North Front St. Grand Island, Nebraska 68803 IMMEDIATE CAUSE IENTEA LLY ONE Mgt,, LINE FOR la). (b). AND (c)I Interval between onset an/d /� /�gearn PART "�1 DUE TO, OR AS A CONSEOUENCk OF Interval between onset and deatr. DUE TO, OR AS A CONSEQUENCE OF Interval between onset and dean Idl I OTHER SIGNIFICANT CONDITICNS Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A AUTOPSY REFER y AS CASE RED TO MEDICAL PART PREGNANCY II IN THE PAST 3 MONTHS' E %AMINER OR CORONER' (Ages 10.541 Yes No Vzs No Ves No 26a Accident Undelermmen 261b DATE OF INJURY /Mo.. Day. Y[) IF 26C HOUR OF INJURY M 26d. DESCRIBE HOW INJURY OCCURRED Swede Pending 26' a IN,IIIRV AT WORK 26i PLACE QF INJURY -At home. farm, street. factory o ice bonding, etc (Specify) 26g. LOCATION STREET OR R D NO CITY OR TOWN STAFF ❑Homicide investigation tle investigation Yes[—] No ❑ 7 DATE OF DEATH /Mo Day YrI 28a DATE SIGNED (Me Day Yrl 28b TIME OF DEATH 5/11/98 >�� 5/20/98 11:08 a.m. M i ° 7 DATE SIGN l D TIME OF DEATH 28c PRONOUNCED DEAD IMo Day. Yrl 28d. PRONOUNCED DEAD (Hour) ♦MO' `(Yr;I �0 g M d To the bet of my knowledge. oc urred al he ti me. date tl D ace and due to the 28e. On the basis of examination and or investigation, m my opinion death occurred at - ° a ° causelsl stated ° the time, date and place and due to the causelsl stated. lS� nature and Title) ► IS nature and Tile ► .DID TOBACCO USE CONTRIBUTE TO TH DEATH? HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30 AS CONSENT GRANTED' ❑ YES NO ❑ OWN ❑ YES �ICO ❑ YES P-116 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN BONER S PHYSICIAN OR COUNTY ATTORNEY) /Type a Print) 68803 32a q 32b DATE FILED BY REGISTRAR (Mo.. Day Yc) )AeAf "�� MAY 2 71998 17 !t.