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VOM TOSS COPYCATS IM RAISED SEAL OF THE NEBRASKA HE MAW VICES
<br />SYSTEM, R COMM IM BELOW TO BE A TRUE COPY OF THE ORONAL- D Ii► } i,WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT1IYHII i IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE -
<br />2/18/2004 200405 47
<br />LINCOLN, NEBRASKA HEALTH j_ SYl4TEM
<br />�UN9��/�111Y
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH n A n l� r" �q,
<br />7
<br />I. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX -
<br />3. DATE OF DEATH /Month. Day. Year/
<br />Cashmere Janulewicz
<br />Female
<br />I February 9, 2004
<br />4. CITY AND STATE OF BIRTH /dnot in U.S.A. name country/
<br />5a. AGE -Last Birthday
<br />T
<br />=
<br />6. DATE OF BIRTH tMondt Day. Year/
<br />(Yrs.) sb.
<br />Mos. DAYS
<br />C
<br />177
<br />CC/)
<br />October 11, 1910
<br />7. SOCIAL SECURTIY NUMBER
<br />Ba. PLACE OF DEATH
<br />505 -48 -6738
<br />HOSPRAL M Inpatient OTHER: ❑ Nursing Home
<br />11 ER Oulpadent E] Residence
<br />8b. FACILITY -Name //J not instift", give street and number)
<br />St. Francis Medical Center
<br />❑ DOA Omer/SpecrtV,
<br />8c. CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island I Yes ED No ❑
<br />Hall
<br />9a RESIDENCE - STATE
<br />9b, COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Cooe)
<br />CITY LIMITS
<br />Nebraska
<br />Hall
<br />�'
<br />314 8. Vine St. 68801
<br />C D
<br />PIZ =
<br />11. ANCESTRY le.g.. Italian. Mexican, German, etc)
<br />' 2 R MARRIED :U WIDOWED
<br />13. NAME OF SPOUSE tll mie. give maiden name/ .
<br />etc.) (Specify(
<br />White
<br />(Specify(
<br />Polish
<br />r`
<br />Stephen Janulewicz (Dec)
<br />14a. USUAL OCCUPATION /Give kind of work done during mast 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />d working life. even iJretired)
<br />Ell Io -,z) College 11 -4 or s -I
<br />Homemaker
<br />Domestic
<br />nknowndany
<br />16. FATHER -NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Lawrence S otanski
<br />Helen Krolikowski
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a.INFORMANT -NAME
<br />(Yes. M. a wk.) Qf yes. give war and dates at services)
<br />N I --- - - - - --
<br />Patricia Janulewicz
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />314 S. Vine St. , Grand Island Nebraska 68801
<br />20. EMB LMER -SIGN URE 8 CENSE NO.
<br />21 a METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />r
<br />®Burial ❑Removal
<br />Feb. 13 2004
<br />Westlawn Memorial .Park
<br />22a. FUNERAL HOM&FNAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />M F1
<br />�Cremation ElDonxtori
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. IMMEDIATE CAUSE . (ENTER ONLY ONE CAUSE PER LINE FOR la). fl). AND (q) I Interval between onset and death
<br />XPART I 1 ` .
<br />M
<br />r it,) I
<br />DUE TO. OR AS A CONSEQUENCE OF: I Interval be en onset and death
<br />I
<br />I
<br />c)
<br />PA T OTHER SIGNIFICANT CONDITIONS - Conditions contributing to me death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />` PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -54) Yes No
<br />11
<br />N
<br />26a. I 1
<br />2667 DATE OF INJURY /MO.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />❑ Accident ❑ Undetermined
<br />D
<br />M
<br />❑ Suicide n Pending
<br />CD
<br />26f. PLACE OF, INJURY - At home, farm. street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigatlop
<br />❑❑
<br />Yes No ❑
<br />office building, etc. /Specify)
<br />O
<br />27a. DDOF DE#XW, (Mg.. Day. Yr)
<br />28a. DATE SIGNED /Mo.. Day. Yr.)
<br />co
<br />All of Lot Three (3), in Block Seven (7), of
<br />Koehler
<br />Place, in the City of Grand Island,
<br />Hall County, Nebraska.
<br />27b. DATE SIGNED (Mo.. Day. Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yr.)
<br />28d. PRONOUNCED DEAD /HOUiI
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<br />VOM TOSS COPYCATS IM RAISED SEAL OF THE NEBRASKA HE MAW VICES
<br />SYSTEM, R COMM IM BELOW TO BE A TRUE COPY OF THE ORONAL- D Ii► } i,WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT1IYHII i IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE -
<br />2/18/2004 200405 47
<br />LINCOLN, NEBRASKA HEALTH j_ SYl4TEM
<br />�UN9��/�111Y
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH n A n l� r" �q,
<br />7
<br />I. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX -
<br />3. DATE OF DEATH /Month. Day. Year/
<br />Cashmere Janulewicz
<br />Female
<br />I February 9, 2004
<br />4. CITY AND STATE OF BIRTH /dnot in U.S.A. name country/
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH tMondt Day. Year/
<br />(Yrs.) sb.
<br />Mos. DAYS
<br />5c. HOURS' MINS.
<br />Ashton, Nebraska
<br />93
<br />October 11, 1910
<br />7. SOCIAL SECURTIY NUMBER
<br />Ba. PLACE OF DEATH
<br />505 -48 -6738
<br />HOSPRAL M Inpatient OTHER: ❑ Nursing Home
<br />11 ER Oulpadent E] Residence
<br />8b. FACILITY -Name //J not instift", give street and number)
<br />St. Francis Medical Center
<br />❑ DOA Omer/SpecrtV,
<br />8c. CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island I Yes ED No ❑
<br />Hall
<br />9a RESIDENCE - STATE
<br />9b, COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Cooe)
<br />CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />314 8. Vine St. 68801
<br />TINSIDE
<br />sK "° El
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY le.g.. Italian. Mexican, German, etc)
<br />' 2 R MARRIED :U WIDOWED
<br />13. NAME OF SPOUSE tll mie. give maiden name/ .
<br />etc.) (Specify(
<br />White
<br />(Specify(
<br />Polish
<br />NEVER DIVORCED
<br />MART
<br />Stephen Janulewicz (Dec)
<br />14a. USUAL OCCUPATION /Give kind of work done during mast 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />d working life. even iJretired)
<br />Ell Io -,z) College 11 -4 or s -I
<br />Homemaker
<br />Domestic
<br />nknowndany
<br />16. FATHER -NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Lawrence S otanski
<br />Helen Krolikowski
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a.INFORMANT -NAME
<br />(Yes. M. a wk.) Qf yes. give war and dates at services)
<br />N I --- - - - - --
<br />Patricia Janulewicz
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />314 S. Vine St. , Grand Island Nebraska 68801
<br />20. EMB LMER -SIGN URE 8 CENSE NO.
<br />21 a METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />r
<br />®Burial ❑Removal
<br />Feb. 13 2004
<br />Westlawn Memorial .Park
<br />22a. FUNERAL HOM&FNAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sondermann F.H.
<br />�Cremation ElDonxtori
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. IMMEDIATE CAUSE . (ENTER ONLY ONE CAUSE PER LINE FOR la). fl). AND (q) I Interval between onset and death
<br />XPART I 1 ` .
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />r it,) I
<br />DUE TO. OR AS A CONSEQUENCE OF: I Interval be en onset and death
<br />I
<br />I
<br />c)
<br />PA T OTHER SIGNIFICANT CONDITIONS - Conditions contributing to me death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />` PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes No
<br />26a. I 1
<br />2667 DATE OF INJURY /MO.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />❑ Accident ❑ Undetermined
<br />M
<br />❑ Suicide n Pending
<br />268. INJURY AT WORK
<br />26f. PLACE OF, INJURY - At home, farm. street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigatlop
<br />❑❑
<br />Yes No ❑
<br />office building, etc. /Specify)
<br />27a. DDOF DE#XW, (Mg.. Day. Yr)
<br />28a. DATE SIGNED /Mo.. Day. Yr.)
<br />28b TIME OF DEATH
<br />1
<br />_
<br />M
<br />27b. DATE SIGNED (Mo.. Day. Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yr.)
<br />28d. PRONOUNCED DEAD /HOUiI
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<br />G }
<br />-U-1
<br />'r k 1:35 M
<br />g
<br />M
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<br />5
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<br />27d. To the best of my knowletlge. tl occurred the time. date and place and due to the
<br />28e. On the basis a examination and or investigation, in my opinion death occurred at
<br />n
<br />ausia s) stated.
<br />u a
<br />the time, date and place and due to the causes) stated.
<br />ISi nature an
<br />(Signature and Tide ►
<br />29. DID TOBACCO USE CONTRIBUTE TO TH ?
<br />RGAN OR TISSUE DONATION BEEN CONSI ED? 30.b
<br />WAS CONSENT GRANTED?
<br />X F YES NO UNKNOWN
<br />V YES NO
<br />�i YES 5.�
<br />31, NAME AII ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type 0r Pdn"
<br />-i3
<br />�-
<br />32a REGISTRAR
<br />326. DATE FILED BY REGISTRAR (Ma. Day. Yr.)
<br />FEB 17 2004
<br />N
<br />CD
<br />CD _
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<br />C3 �
<br />cn
<br />s CD
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