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<br />LEGAL: Lot Fourteen (14), in Block One (1), in College Addition to West Lawn,
<br />in the City of Grand Island, Hall County, Nebraska.
<br />WHEN TH O COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR1G1M4W?ECqWON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAVXMW $ D€JON WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />NLEYS- COQIPER .
<br />DEC 5 2000 11 (SrAW STATETiEGISYRAR
<br />LINCOLN, NEBRASKA HEALTH)'iNDM MI AN gERW10ES$LESTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SFgVICESFINANC1ihND SUPPORT
<br />vrrAL STATISTICS -
<br />CERTIFICATE OF DEATH, __-
<br />1 DECEDENT -NAME FIRST MIDDLE LAST
<br />2 SE%
<br />3 DATE OF DEATH .MOnrll D.n. Yean
<br />Jack Laurence Bydalek
<br />Male '
<br />November 23, 2000
<br />4 C17Y AND STATE OF BIRTH lit not n US A.. name country;
<br />5a AGE Last BlnhdaY
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />6. DATE OF BIRTH rMonth. Da;, Year;
<br />sh MOS DAYS
<br />5° HOURS MINS
<br />Ashton, Nebraska
<br />Y"�4
<br />September 8, 1936
<br />�=
<br />c-) co
<br />506 -40 -1784
<br />-
<br />a causels) stated the time. (late and place and due Ib the causelsl stated.
<br />❑ ER Outpatient ❑ Residence
<br />FACILITY ltl nohnsiltulion, street and number/
<br />Bb -Name grve
<br />St . Francis Memorial Health Care Center
<br />M
<br />Sc CITY TOWN OR LOCATION OF DEATH
<br />Btl INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand island
<br />Yes Ri No ❑
<br />t"9
<br />n
<br />Z
<br />19c CITY. TOWN OR LOCATION
<br />n+`
<br />m
<br />Hall
<br />-. m
<br />o
<br />10 RACE - (e. g., White. Black. Amencan Indian 11. ANCESTRY leg. Italian. Mencan. German. etc,
<br />M
<br />C/)
<br />H
<br />NEVER DIVORCED
<br />7C
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<br />❑ MARRI
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<br />LEGAL: Lot Fourteen (14), in Block One (1), in College Addition to West Lawn,
<br />in the City of Grand Island, Hall County, Nebraska.
<br />WHEN TH O COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR1G1M4W?ECqWON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAVXMW $ D€JON WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />NLEYS- COQIPER .
<br />DEC 5 2000 11 (SrAW STATETiEGISYRAR
<br />LINCOLN, NEBRASKA HEALTH)'iNDM MI AN gERW10ES$LESTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SFgVICESFINANC1ihND SUPPORT
<br />vrrAL STATISTICS -
<br />CERTIFICATE OF DEATH, __-
<br />1 DECEDENT -NAME FIRST MIDDLE LAST
<br />2 SE%
<br />3 DATE OF DEATH .MOnrll D.n. Yean
<br />Jack Laurence Bydalek
<br />Male '
<br />November 23, 2000
<br />4 C17Y AND STATE OF BIRTH lit not n US A.. name country;
<br />5a AGE Last BlnhdaY
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />6. DATE OF BIRTH rMonth. Da;, Year;
<br />sh MOS DAYS
<br />5° HOURS MINS
<br />Ashton, Nebraska
<br />Y"�4
<br />September 8, 1936
<br />7 SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ® N.,, Home
<br />506 -40 -1784
<br />-
<br />a causels) stated the time. (late and place and due Ib the causelsl stated.
<br />❑ ER Outpatient ❑ Residence
<br />FACILITY ltl nohnsiltulion, street and number/
<br />Bb -Name grve
<br />St . Francis Memorial Health Care Center
<br />❑ DOA ❑ Othe, rSpe<-A
<br />Sc CITY TOWN OR LOCATION OF DEATH
<br />Btl INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand island
<br />Yes Ri No ❑
<br />Hail
<br />9a RESIDENCE - STATE
<br />9b COUNTY
<br />19c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER ;;ncludrng Zip ' 9e INSIDE CITY LIMITS
<br />6803
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2309 N. Sheridan Ave. Yes ® No ❑
<br />10 RACE - (e. g., White. Black. Amencan Indian 11. ANCESTRY leg. Italian. Mencan. German. etc,
<br />12 FXJ MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE Mwde give ma,den +lame+
<br />etc I fSoec,fy ISpec,fy
<br />White American
<br />NEVER DIVORCED
<br />Barbara Miller
<br />❑ MARRI
<br />14a JSUAL OCCUPATION IGrve kind of work done during most ""KIND OF BUSINESS INDUSTRY
<br />of work,og life, even it retired)
<br />School Teacher OF
<br />t 5 tuUL.A I IUN (Specify only nAl
<br />Elementrir Secondary 10 121
<br />16 FATHER - NAME anal NIIV— --
<br />Cyrus Bydalek Clara
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES' ;;199a INFORMANT - NAME
<br />IYes no. as k., I (it yes. give war and dates of se -cell '', Barbara Bydalek
<br />19b INFOMANT MAILINGADDRESS (STREET OR R.F D NO CITY OR TOWN STATE ZIP,
<br />2309 N. Sheridan Ave., Grand Island, NE. 68803
<br />20 EMB MER - SIGNATURE B LICENSE NO i/ 3 21a METHOD OF DISPOSILON 1 'To DATE
<br />y
<br />/ n L4ov. . 27 , 2000
<br />J77L( ', -.1- ( i�� �i. X 3r�al ❑R. n..�
<br />MIUULE
<br />completed,
<br />Couite I
<br />)EN SURNAME
<br />Nowicki
<br />21c CEMETERYUH(:H1,MAIUHY NAMt
<br />Grand Island Cemetery__
<br />22. FUNERAL H E - NAME 210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN
<br />Apfel- Butler - Geddes ❑ Crema " °" ❑ ° °na " °" Grand Island, NE.
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP)
<br />1123 W. 2nd Street, Grand Island,Nebraska 68801
<br />1 23 PAR IMMEDIATE CAUSE (ENT R ONLY ONE CAUSE PER LINE
<br />jNNE RR �b�. AANDD!,c1/1'�
<br />R
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />IbDI!E TO OR AS A CONSEQUENCE OF'
<br />Interval between ousel
<br />Interval In of ° neary
<br />Inlervai L41wee� once' �. ' �'
<br />ICI
<br />OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related
<br />PART III IF FEMALE. WAS THERE A 124 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL
<br />PAHI _
<br />PREGNANCY IN THE PAST 3 MONTHS EXAMINER OR CORONER'
<br />11
<br />(Ages 10.541 Yes No Yes No Ves ❑ No -
<br />25.
<br />i
<br />26b DATE OF INJURY (Mo. Day Yr.)
<br />26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />Su�c,tle Pending 26e INJURY AT WORK 1 261 PLACE OF INJURY - At home farm, street tactav 26q LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />_ ofM1Ce buedng. etc (Specify)
<br />Hom,cltle Investigation Yes ❑ No ❑
<br />— _T� -_..
<br />27a. DATE Of DEATH Day Yy 28a DATE SIGNED 10, Day Yc; 28b TIME F DEATH
<br />{(MO.
<br />41 --
<br />vU_i 27b. DATE SIGNED /Mo.. Day. Yrl 27c TIME OF DEATH _� a ° 26c PRONOUNCED DEAD IMO.. Day. Yrl 28d. PRONOUNCED DEAD lHOUn
<br />o � M
<br />�.8 �oo °N =_J
<br />g M g
<br />Ig -
<br />I ' � 27tl. To the best my knowledge . death occurred at the 'me. (late arW place antl due to the ° ° 28e On the basis of exam,naUOn and or mvesl,gatlon, m my opinion deam occurred at
<br />a causels) stated the time. (late and place and due Ib the causelsl stated.
<br />(Signature and Title) 10 15, nature and Tile 11,
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH'
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'
<br />30 b WAS CONSENT GRANTED'
<br />❑ YES ❑ NO UNKNOWN
<br />❑ VES �O
<br />❑ YES NC
<br />--
<br />31 NAME ANU AUUHESS Ur UtH I IVEM fi- m —UnN. —M-1 — 11— + " ..., I —
<br />Sitki Copur M.D. 2116 W. Faidley, Grand Island, NE. 68803
<br />J2b UA I E EILEU Ely HEUIJ I HAM fW Uay "I
<br />DEC 12000
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