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Kuszak Female June 24, 1998 <br /> A.C�TV qND STATE OF BIRTH /llnol n U S.A..nams counhy/ Sa.AGE-last&rlhCay UNOER t VEAF UNDER�DAV 8.DATE OF BIRTM /MOnM.Day.Veaq <br /> Farwell, Nebraska �`'f5' �O SbMOS DAVS x�ouRS M�NS March 27� 172� <br /> 0 <br /> 7 SOCIAL SECURTIV NUMBER Ba.�LACE OF DEATH � <br /> 508-44-7311 HOSPITAL � i�oatiem OTHER � NursmgMdme <br /> Bp FACIUTV-Name /NnphnSfiNtion.give shBBf a�d�umberJ � � EF OWpatient � RssiOence <br /> St. Francis Medical Center ❑ ooA ❑ a���s�,ti, <br /> & C�T�70WN OR IOCAT�ON OF OEATH BC WSIOE CITY UMITS Be COUNTV OF DEATH ' <br /> Grand Island �ag � N� ❑ Hall <br /> 9a RESIDENCE-STATE 9b COUNTY 9t.CITY.TOWN OR LOCATION � 9�.STREET AND NUMBER /MtWdrgliD Co�el 9e iNSIDE CITV uMITS ,__ <br /> a-Il " Grand Island 2414 N. Howard 68803 � YBS XD No❑ <br /> 10 AACE-(e.g..Whita.Black.Ameneen InOiaa 11.ANCESTRV le.g..flelian.Mexican.German.elq 1(� t 2.❑MARRIED �WIDOWED 13.NAME OF SPOUSE /ll wde.give maMen namel <br /> etc.l�Scec�Nl ISpeaNl J <br /> White Polish/American NEVEA DIVORCED Leo T. Kuszalt <br /> MA <br /> 1Aa USUALOCCUPATION IGrvekinddwakddraCuringmasl�n� 14D KINDOFBUSINESSINDUSTRV ,^^!l 15.EDUCATION ISpec�ryoniyniqhsttqnEecompietea� <br /> d working li/e,Bven i/refir9d) � Gj�� Ekmentary or SeconAary IO-12) CWbge i��a or 5•i <br /> Food Service Supervisor Ne. Veterans Home 8th Grade <br /> 76.FpTMEF-NAME FIRST MIDDLE LAST �7 MOTHER FIRST MIDDIE MAIDEN SURNAME <br /> Frank NMN Ko erski Vernie NMN Lubash <br /> �8 ri4S DECEnSED EvEP iN US.ARMED FORCES7 t9a iNFORMAN7-NAME <br /> ',Yes�.'1��u�k� !II yes.g�ve war 8fld tlate5 0�SBrviC85) <br />� N� ------ � Marjorie Creason <br /> 19p �NPOAMANT MAIUNG AD�RES$ fSTREET OR R.F D N0.pTV OR TOWN S7ATE.ZIPI <br />� �310 Blauvelt Rd. , Grand Island, Ne. 68803 <br />��EM LME �SIGNATU LICEN NO. � 21a ME7NOOOFDISPOS�iiOh iI210.0ATE 21e CEMETEfi�ORCAEMATORV NAME <br />� j � �r ��/�l <br /> � ❑X s���a� ❑4emo�a� 'June 26, 1998 Westlawn Memorial Park <br /> 22a U RAL HO E- � E �2'J CEME7ER�'OR CAEMATORV LOCA710N CI7Y OA iOWN STAiE <br /> I Livin ston-Sondermann F.H. ❑c`e"'a"°" ❑°°"d"°"� Grand Island, Nebraska <br /> 2ffi F�1N[RAl N�ME ADDRESS �STREET OA A.F.D.NO.CITY OA T�N/N STATE.ZIP� � <br /> 5U1 N. Webb Road, Grand Island, Ne. 68803-4050 <br /> 23 iMMEDIATE CAUSE IENTER ONLY ONE CAUSE PEA LINE FOR ia'..I��.AND Icp � ��le�val Detwee�onset aM tleam <br /> �PART ��'�La��"�4,'�'l.�����V�'1 ��/�U{^ i.� � I I�I�. <br /> la� yv <br /> DUE 70.OR AS A CONSEOUENCE OF� i Imervai between onsei ana deain <br /> L/i �!P <br /> 9 i <br /> IDI <br /> DUE TO.OR AS A CONSEOUENCE OF� � Interval benveen onset ano oeam <br /> i � <br /> Icl � � <br /> 07HER SIGNIFICANT COND�TIONS-ConAitions confribNing lo Me deat�but no��ela�e7 PA6iT 111 IF FFIAALE.W AS TNERE A 'ra AUTOPSP 5.WAS CASE REFEFRED TO MEDiCAL <br /> PA?T��� -( (��� � PREGNANCV IN TH[PAST 3 MONTHS? ✓ E%AMINER OR CORONEFl� <br /> 11 �C <br /> �AgeS�0-5�'i Y05 NO �85 No Ye5 NO <br /> 26a 26b.DATE OF INJURV /MO_Day Yc) 26c MOUR OF WJUR� 2fitl.�ESCRiBE N•W INJUA�OCCURREO � <br /> � 4cc�tlent � U�GelermmeA M <br /> � SwtiOe � Pe�tling 26e INJURV AT WORK 261.P�q CEOF�NJURV-pt home.�arm.svee�.�actory I 2l•g.IOCM1TION STREET OA R F.D.N�. CITV pR TOWN STATE <br /> ❑ ❑ ❑ oXice bu IEing.etc /Speciyl <br /> Nom�aOe invesugatwn Yes No <br /> Da DATE OF DEATH lMO.Oay.Yc1 28a DATE SIGNED /Mo..Day.YrJ 28b iIME OF DEATH <br /> _ .�Gj �Z'� ��� . =w M <br /> s� <br /> �`��,y 27b.OA SIGNE /Ma..Day Yr I 27c TIME OF DEATH � � 28c.PRONOUNCED DEAD /MO..Dsy,Vrl 28d.PRONOUNCED DEAD /HOUn <br /> x�� � � L� ��J � I ,��`�, T i M o��� M <br /> 27tl.To 1 e bast d my knowletlga.CeaM acwretl at the Nme.Gale aM Wace aM tlue io the � 2Be.On the Oaei9 d sKamineGOn eM�or inve5tg2tion.in my opnan Aealh OCCUnsO at <br /> �yauselsl slate0. /�} �.7/ - ° 3� t�e time.Oate and dace an0 tlue to tM causelsi stated. <br /> (Si natwe antl Tilb ► 1.����L `-� /� IS�naWro and TNe <br /> 29.DID TOBACCO USE CONTRIBUTE TO THE DEATH't 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIOEFED? 30.b WAS CONSENT GAANTED� <br /> � VES NO � UNKN6WN S� � VES NO � � �ES NO <br /> 31.NA`M�E AND ADDRESS OF ERTIFIEA IPHVSICIAN,CORONEAS PHVS�CWN Oq COUNTV ATTORNEYI lT a Pnnf/ <br /> �a(' �� ��� C� �IQ�' ��8��( Anne K. Morse, M.D. <br /> 32a.REGISTRAR 320.DATE FILED BY REGISTRAR /MO..Osy.YcJ ' - <br /> . <br /> JUN 3 0 19 <br /> > - <br />„ <br />_ _ _ . . .._. ,:.. _... .. <br /> � <br /> �`'��'�, 9 a�,G�-�'2�,�i F�-�`� °y`R �-t' �1'fJ� ���'',�.-`,' ir ��.f�'�Z <br /> T��,, � .,�,,, � � �� � � � 70 ,� • �����'�� <br /> r+ C� n � � n'� I l�'(�G( �`�`�1- N y'Z. � �'°'► r'�'l..C`(:� ���.� .�'Y.�.�Q. �� <br />