Laserfiche WebLink
YI <br />M <br />C <br />Z <br />y en <br />`lC = <br />n n <br />WREN TM COPY CARRIES T1E RAISED SEAL OF THE NEBRASKA HEAL <br />SYSMAt RCERTMS TM BELOW TO BE A TRUE COPY OF THE ORIGM <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STjd <br />THE LEGAL DEPOSITORY FOR VITAL RECORD& _ <br />DATE OF ISSUANCE _ 200409903 _ <br />OCT 71999 r <br />LINCOLN, NEBRASKA - tia I . HEA <br />i STATE OF NEBRASKA - DEPARTiUNT b <br />Amended October 7, 1999 BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DE-N-71 <br />INANDHUMAN8&nAICE &r r <br />MIR fllll FILE WITH <br />6�0 WHICH IS <br />_ `,-s <br />O <br />(V <br />cD Q. <br />O <br />S to <br />O =3 <br />Cfl <br />GD <br />O CD <br />W = <br />O <br />to <br />cs <br />1. DECEDENT - NAME FIRST MIDDLE UST <br />t-..31 <br />c_> Cn <br />Bertha Teckla Deminski <br />s <br />o -i <br />a. CITY AND STATE OF BIRTH /Mnotin U.S.A. norm counivy/ <br />56. AGE - Land 8"Y <br />UNDER 1 YEAR <br />A ` <br />6 DATE OF BIRTH (Mon - - <br />MOS. DAYS <br />70 <br />) <br />M <br />rn �1 <br />--4 <br />� o <br />7. SOCIAL SECURTIY NUMBER • "� <br />co <br />Tt <br />/ <br />r/Ira/ma <br />❑ ER Oulpatlent ❑ Residence �. <br />M <br />BryanLGH Medical Center East <br />❑ DOA Otlftr /Saeerry, <br />M <br />Bd. INSIDE CITY LIMITS <br />a^ <br />• Lincoln <br />.Yes ® No ❑ I <br />Lancaster <br />!J1 <br />9b. COUNTY <br />N <br />9d. STREET AND NUMBER /krcWMZID Code/ <br />W <br />�c <br />Hall <br />Grand Island <br />D <br />Yea ® Na ❑ <br />Co <br />�i <br />INANDHUMAN8&nAICE &r r <br />MIR fllll FILE WITH <br />6�0 WHICH IS <br />_ `,-s <br />O <br />(V <br />cD Q. <br />O <br />S to <br />O =3 <br />Cfl <br />GD <br />O CD <br />W = <br />O <br />to <br />cs <br />1. DECEDENT - NAME FIRST MIDDLE UST <br />2. SEX - --"` <br />3. DATE OF DEATH /Marla. -W.. YW -- - -- <br />Bertha Teckla Deminski <br />Female <br />September 15,H1999 <br />a. CITY AND STATE OF BIRTH /Mnotin U.S.A. norm counivy/ <br />56. AGE - Land 8"Y <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6 DATE OF BIRTH (Mon - - <br />MOS. DAYS <br />5c. HOURS' MINS. <br />- <br />S►t Paul, Nebraska <br />SD. <br />7 <br />December. 1$ 923 <br />". -� <br />. <br />7. SOCIAL SECURTIY NUMBER • "� <br />. "P ew!E&TAMe - <br />Irrpetleta OTHER <br />HOSPITAL: ® : ❑ Nurskp Holm <br />■ _ 506-28-9294 <br />r/Ira/ma <br />❑ ER Oulpatlent ❑ Residence �. <br />81% FACILITY - Name wax gM abesr end, niknb0/ <br />BryanLGH Medical Center East <br />❑ DOA Otlftr /Saeerry, <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />Bd. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />• Lincoln <br />.Yes ® No ❑ I <br />Lancaster <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /krcWMZID Code/ <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />419 N. Waldo 68803 <br />Yea ® Na ❑ <br />10. RACE - (e.g.. Who. Bieck. Annerieen Wien. <br />11. ANCESTRY le.g.. Ratan. Moxieart German, atc) <br />12. ❑ MARRIED ® WIDOWED <br />13, NAME OF SPOUSE /a rifle give maiden name/ <br />eta) (Specdy) <br />White <br />I I <br />I o ish German <br />NEVER DIVORCED <br />August Deminski, Sr. <br />1 <br />14a. USUAL OCCUPATION (Give kkrdd rode cone dlakrg marl 14b. <br />KIND OF BUSINESS INDUSTRY <br />1 S EDUCATION ISpeeity onty highest grade completed) <br />Elemenlery or Secondary 10 -121 Collage (1 -w a 5.1 <br />of working CAF. even l,rsiredl <br />Production Worker <br />Food Industr <br />16. FATHER -NAME FIRST MIDDLE LAST 17. <br />MOTHER - FIRST MIDDLE MAIDEN SURNAME <br />Frank Sack <br />Teckla <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />rya. no a k.* l Id Yes. give war and dams d services) <br />No <br />August Deminski, Jr. _ <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIP) <br />419 N. Waldo Grand Island, Nebraska 68803 <br />20. EMBA ER - SIGNATURE 8 LIC N0- <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />% <br />❑x Bunal ❑Rerrroval <br />Sept. 20 1999 <br />Westlawn Memoriq &gff�r <br />22a. FUNERAL HOME - NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Kleine Funeral Home <br />❑Cn.. ❑Donahv <br />Grand Island Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />3213 W. North Front Street Grand Island, Nebraska 68803 -4050 <br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (b). AND Icl) I Interval between onset and death <br />I <br />PRAT <br />I lal I � t a'l V 'IL' S <br />DUE TO. OR AS WSEGUENCE OF Irwerval between ousel and deem <br />jYIYJ\ ' Vyl i ►ll J s <br />F ro) <br />DUE TO. OR AS A CONSEOUE E OF . wpervz! between onset arw .oath <br />r S <br />(b) c I <br />OTHER SIGNIFICANT CONDITIONS - Conft" caI'ibuliN to the death but not related PART <br />III IF FEMALE. WAS THERE A 24. <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART / / /��D, . - 0 f a�Q - PREGNANCY <br />It A- cu '� 1 k "X Fu 6 I V • v (Ages <br />IN THE PAST 3 MONTH <br />10 -541 Yes No <br />Yes <br />EXAMINER OR CORONER <br />Yes No IV <br />26a. <br />26b. DATE OF INJURY /MO.. Day. Yr/ <br />26c. FOUR OF INJURY <br />26d. DESCRIBE (IOW INJURY OCCURRE D <br />- - . .. <br />El n <br />1 <br />` - - + _ -• <br />. A.-*, Undetermined <br />M <br />Suicide [I Pernot <br />Zee. INJURY AT W0F1K -. <br />20[_PLAC RY•.Nhon�n.1�m.��l�g, -vl <br />,oa6nF�Cee 7s7Fbi cr77 <br />LOCPTJC1aL -- - STR6G7TGRA.F.D. NG---- --- -f:tiY __` -STATE <br />- T �°y°a ", <br />_ <br />1 F/i$Ile'de TJ `. Inye�ugaa°N i <br />�� <br />1) T yes'L_]r No ❑ <br />•, <br />27a. DATE OF DEATH /Ala.. Day. Yr./ <br />2Ba. QATE SIGNED /A41a. Day. Yc/ . .._ _ <br />G <br />28b. _ --- -- <br />TIME OF D �� ► <br />194Q <br />M <br />a <br />280. PRONOUNCED DEAD /MO.. Oay. Yr./ <br />2Bd. PRONOUNCED DEAD /Foal <br />27b. DATE 9IGNED /Ab.. Day Yr/ <br />270. TIME OF DEATH <br />C � <br />E <br />� <br />E <br />a <br />27d. To ft bat d my knowlsdgs occurred at tlr irtre, place and due b the <br />Zee. On me bssis d aaanerlsuon endltx InveeYpeOOR b mr tKrkkan esatln occurred at <br />Cause(s) st"d. 1 <br />a <br />On ims. daft and place and due b Ile CauaNsl 31019d. <br />' <br />and Tpe <br />end - <br />29. DID TOBACCO <br />USE CONT O E DEATH? a FIRS OR TISSUE DONAT - BEEN CONSIDERED? <br />30b WAS CONSENT GRANTED? <br />❑ ❑ 11NICN0WN ❑ NO <br />El YES k, <br />YES I;1/- _.. <br />31. NAME AND ADDRESS OF CERTI (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) 11900 a natg <br />32a REGISTRAR � � /^� 32b. DATE FILED BY RV P 2 01999. <br />LFrPL: Lots £iahty Nine (89) and Ninety (90) Felmont Addition to the city of <br />r-rand Island, hall Countv, Nebraska <br />