|
n
<br />a
<br />M =
<br />2. SEX
<br />3. DATE OF DEATH /Month Day Yaw)
<br />John Walter Rojewski Jr,
<br />C _
<br />April 21, 1995
<br />♦. CRY AND STATE OF BIRTH 19 not n U S A name Country) 5a AGE - Last Birthday UNDER 1 YEAR
<br />m
<br />Z
<br />n
<br />o �-i*
<br />O
<br />Ba PLACE OF DEATH
<br />n N
<br />z_!
<br />N
<br />❑ ER Outpatient Residence
<br />7C = M
<br />--1 rn
<br />O
<br />k. CITY. TOWN OR LOCATION OF DEATH
<br />Id INSIDE CITY LIMITS
<br />Ile COUNTY OF DEATH
<br />O
<br />I Y
<br />co
<br />9a. RESIDENCE -STATE
<br />9b COUNTY
<br />9d. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /arcaaarg Zip Code/
<br />rn
<br />Nebraska
<br />Ste
<br />-
<br />i> ct
<br />O
<br />10. RACE - (a.g, Wlkte. Black. Amencan Indian
<br />fC7 1
<br />{- D
<br />CA)
<br />r" `g°""' White
<br />`S°°""' Danish/Polish
<br />I
<br />" RER DIVORCED
<br />Betty Jameson
<br />�
<br />N
<br />CD
<br />�
<br />f_a
<br />tii v
<br />d Me, even d reared/
<br />Main enance Man
<br />I
<br />�,r
<br />0
<br />16. FATHER -NAME FIRS' MIDDLE LAST "
<br />1]
<br />Z
<br />(dec.) Elvina Kristine Jensen
<br />'
<br />t9a INFORMANT -NAME
<br />0
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATEDEPARTMENT OF HEALTH,
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIPI
<br />1820 W. John Street Grand Island, NE 68803
<br />20. EMI�Ir1ER - SIGNATURE 6 NO
<br />IT CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECO -P f)Ai AUINTH THE STATE
<br />21b. DATE
<br />21c. CEMETERY OR CREMATORY - NAME
<br />rL7y \L
<br />kg
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH: _ :LEG. 0�"Y FOR
<br />4 p r. 26, 1995
<br />Elmwood Cemetery
<br />22a FUNS - NAME
<br />_
<br />VITAL RECORDS.
<br />Jacobsen Funeral Home
<br />❑°' ❑'
<br />St. Paul Nebraska
<br />DATE OF ISSUANCE
<br />2 0 �'�0 5 2
<br />411 "0" Street St. Paul, Nebraska 68873
<br />23, IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR lal. (b), AND (cll Interval between onset and death
<br />PART eAfZ pro )P << c=Sr
<br />MAY 17 1995 STANLEY S. COOPER; - DIRECTOR
<br />DUE TO. OR AS A CONSEQUENCE OF - Interval between onset and death
<br />A S 1 2 A J
<br />(b) p
<br />LINCOLN, NEBRASKA BUREAU OF WAL ST fiTISTICS
<br />,dI J6 Dv2tfiL c
<br />OTHER SIGNIFICANT CONDITIONS - CdndAOns conhW^ to to death but nd related PART
<br />PART PREGNANCY
<br />If Q R c N az r=te (� J 2 ©� y�
<br />III IF FEMALE. WAS THERE A
<br />IN THE PAST 3 MONTHSn
<br />STATE OF NEBRASKA - DEPARTMENT OFAEALTN
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'
<br />(Ages
<br />10 -54) Yes No
<br />BUREAU OF VITAL STATISTICS
<br />Yes No
<br />26a
<br />26b . DATE OF INJURY JW. Day. Yr./
<br />CERTIFICATE OF
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />[� Ax10ent ❑ Undetermined
<br />Unk.
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month Day Yaw)
<br />John Walter Rojewski Jr,
<br />Male
<br />April 21, 1995
<br />♦. CRY AND STATE OF BIRTH 19 not n U S A name Country) 5a AGE - Last Birthday UNDER 1 YEAR
<br />UNDER I DAY 6. DATE OF BIRTH t~, Day Year)
<br />!Vrs 50 MOS DAYS
<br />St. Paul, Nebraska 69
<br />Sc HOURS MINE June 24, 192 J
<br />7 SOCIAL SECURTIY NUMBER
<br />Ba PLACE OF DEATH
<br />506 -20 -3115
<br />HOSPITAL ® I^pabent OTHER ❑ Nursing Home
<br />--
<br />❑ ER Outpatient Residence
<br />8. FACILITY - Name ie nor asatiadih, give sheet end nunMer/
<br />University of Nebr. Medical Center
<br />❑ DOA ❑ DIn«(Specer1
<br />k. CITY. TOWN OR LOCATION OF DEATH
<br />Id INSIDE CITY LIMITS
<br />Ile COUNTY OF DEATH
<br />Omaha
<br />I Y
<br />I Douglas
<br />9a. RESIDENCE -STATE
<br />9b COUNTY
<br />9d. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /arcaaarg Zip Code/
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />11820 W. John St. 68803
<br />1 Yes ® No ❑
<br />10. RACE - (a.g, Wlkte. Black. Amencan Indian
<br />11. ANCESTRY le g.. IWan, Mexican. Gemnw. eto1
<br />t2. ® MARRIED a WIDOWED
<br />13 NAME OF SPOUSE (a wAe. gne maiden name/
<br />r" `g°""' White
<br />`S°°""' Danish/Polish
<br />I
<br />" RER DIVORCED
<br />Betty Jameson
<br />14a. USUAL OCCUPATION tab.
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION ISpenty only highest grade c-,~)
<br />d Me, even d reared/
<br />Main enance Man
<br />I
<br />Hall Count Housing
<br />Ebmerga�or Secondary (0 -12) College 11 -a or 5-i
<br />III
<br />16. FATHER -NAME FIRS' MIDDLE LAST "
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />(dec.) John Rojewski Sr.
<br />(dec.) Elvina Kristine Jensen
<br />16. WAS DECEASED EVER IN US ARMED FORCES'
<br />t9a INFORMANT -NAME
<br />. n of servce) Yeea s roa uracl 0. e a10 -26- 43/ 2 -21 -46
<br />Betty Rojewski
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIPI
<br />1820 W. John Street Grand Island, NE 68803
<br />20. EMI�Ir1ER - SIGNATURE 6 NO
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />21c. CEMETERY OR CREMATORY - NAME
<br />rL7y \L
<br />kg
<br />❑Reme,.al
<br />4 p r. 26, 1995
<br />Elmwood Cemetery
<br />22a FUNS - NAME
<br />210. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Jacobsen Funeral Home
<br />❑°' ❑'
<br />St. Paul Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />411 "0" Street St. Paul, Nebraska 68873
<br />23, IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR lal. (b), AND (cll Interval between onset and death
<br />PART eAfZ pro )P << c=Sr
<br />,,2 1
<br />DUE TO. OR AS A CONSEQUENCE OF - Interval between onset and death
<br />A S 1 2 A J
<br />(b) p
<br />DUE TO. OR AS A CONSEOUENCE OF Interval between onset and death
<br />S 7-f e n Z_�-o "" 4.
<br />,dI J6 Dv2tfiL c
<br />OTHER SIGNIFICANT CONDITIONS - CdndAOns conhW^ to to death but nd related PART
<br />PART PREGNANCY
<br />If Q R c N az r=te (� J 2 ©� y�
<br />III IF FEMALE. WAS THERE A
<br />IN THE PAST 3 MONTHSn
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'
<br />(Ages
<br />10 -54) Yes No
<br />Yes Ixo
<br />Yes No
<br />26a
<br />26b . DATE OF INJURY JW. Day. Yr./
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />[� Ax10ent ❑ Undetermined
<br />Unk.
<br />Unk.
<br />Motor vehicle accident
<br />M
<br />❑ Suchda ❑ PerXMhg
<br />URY AT WORK
<br />26f, PLACE OFD INJURY ;N thornel farm. sheet. factory
<br />M
<br />26g. LOCATION ST EET OR R F.D. NO CITY OR TOWN STATE
<br />❑ Halacide Investigation
<br />es ' No ❑
<br />Unk.
<br />Unk.
<br />27a DATE OF DEATH (Mo Day Y0
<br />28a DATE SIGNED (MO_. Day. Yr)
<br />28b TIME OF DEATH
<br />4
<br />1 ( ^ �s
<br />- P IZ L, 2,1 y
<br />�
<br />M
<br />`d,
<br />Q
<br />$ i
<br />27b DATE SIGNED !MO Dav Yr
<br />27c TIME OF DEATH
<br />28C PRONOUNCED DEAD (MO.. Day. Yr l
<br />28d. PRONOUNCED DEAD (Hour,
<br />APfZIL L 11 F1
<br />fO P,/- M
<br />M
<br />L27d.
<br />° o
<br />To the beef of my knowledge dear ed , dae Sind place and due to the
<br />cause(s1 staled. RO U
<br />260. On the basis of exammation and a investigation. in my opinion death occurred of
<br />to ome, date and and due to dm cahnelsl stated.
<br />-
<br />M A S s
<br />(Signatfire and Tae) ► A 1 _ ✓
<br />place
<br />I nature and Trig ►
<br />,29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED'
<br />❑ YES ❑ NO © UNKNOWN
<br />❑ YES K NO ❑ YES ❑ NO
<br />31 NAME AND ADDRESS OF CERTIFIFA fPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type o Prix)
<br />Admass Hailu MD 600 S. 42nd St. Omaha, NE 6819P UNMC
<br />32a. REGIST s 7 ....
<br />32b DATE FILED BY R - EG15 (Ab.. Da, fl 19
<br />LEGAL: Lot Seven (7) and the Easterly Six (6) feet of Lot Six (6) in Block Fifty
<br />Three (53), in Charles Wasmer's Second Addition to the city of rrand Island, Fal
<br />County, Nebraska
<br />
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