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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANNIUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINALIW 'aN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISner- SEctiC ;v141CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />..
<br />DATE OF ISSUANCE rl
<br />200504554MPER.
<br />11 /2/2004 AtA%STR4R
<br />LINCOLN, NEBRASKA HEALTH ANO NWA4,SE T.EM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVfa$ AND] $qP_POIjT J J
<br />VITAL STATISTICS 1
<br />= 4 'JI.
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST 2.. SEX - `3i' ATE OF: DEATH IMonth. pay. Year)
<br />t b
<br />Loretta
<br />(NMI) Chelewski
<br />Female
<br />Oc o er 22, 2004
<br />4. CITY AND STATE OF BIRTH 111 not in USA., name country!
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6, DATE OF BIRTH iMonth. Day. Year)
<br />Hazard, Nebraska
<br />(Vrs.l
<br />77
<br />5b. MOS� I DAYS
<br />5c. HOURS MINS.
<br />January 31, 1927 T
<br />7 SOCIAL SECURTIV NUMBER
<br />Be. PLACE OF DEATH
<br />HOSPITAL Inpatient OTHER: 0 Nursing Home
<br />C') U)
<br />C=)
<br />f
<br />ER Outpatient Residence
<br />Z
<br />rn
<br />2
<br />❑
<br />,
<br />_3
<br />❑ DOA Other /8p6crtyt
<br />(V
<br />8d. INSIDE CITY LIMITS
<br />ee. COUNTY OF DEATH
<br />Grand island
<br />_
<br />Yes ® No []
<br />H411
<br />,
<br />9b. COUNTY
<br />CD
<br />OR LOCATION
<br />9d. STREET AND NUMBER /including3p Code)
<br />M
<br />a
<br />en
<br />Hall
<br />Grand Island
<br />-,
<br />�INSIDE
<br />Nn
<br />`YI
<br />c a
<br />12. ❑ MARRIED ® WIDOWED
<br />13. NAME OF SPOUSE (it wife .give maiden name)
<br />etc.) (specify) White
<br />Specify' American
<br />NEVER DIVORCED
<br />14a. USUAL OCCUPATION (Give kind of work done
<br />during most
<br />M FIRE
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed) _
<br />of working life, even if refired)
<br />Elem ytay or Secondary ID -12) College 11 -4 or s•I
<br />Homemaker
<br />Own Home
<br />JL
<br />18. FATHER - NAME FIRST MIDDLE
<br />7E I""'
<br />cD
<br />Otto
<br />Krous
<br />Lennie White
<br />18. WAS DECEASED EVER IN U,S, ARMED FORCES?
<br />19a. INFORMANT
<br />- NAME
<br />)Yes. no. or unk.)
<br />(If yes, give war and dates of services)
<br />$ o b C h e l ew s k i
<br />No
<br />•
<br />�,
<br />CF)
<br />Cn �rw
<br />uT
<br />►-
<br />°'
<br />�.
<br />a
<br />'
<br />CL]
<br />W
<br />-
<br />2
<br />S, 5C)
<br />Lot Fifteen (15), Block
<br />One (1),
<br />Morris
<br />Addition
<br />to
<br />the City
<br />Of Grand Island, Hall
<br />County,
<br />Nebraska.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANNIUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINALIW 'aN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISner- SEctiC ;v141CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />..
<br />DATE OF ISSUANCE rl
<br />200504554MPER.
<br />11 /2/2004 AtA%STR4R
<br />LINCOLN, NEBRASKA HEALTH ANO NWA4,SE T.EM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVfa$ AND] $qP_POIjT J J
<br />VITAL STATISTICS 1
<br />= 4 'JI.
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST 2.. SEX - `3i' ATE OF: DEATH IMonth. pay. Year)
<br />t b
<br />Loretta
<br />(NMI) Chelewski
<br />Female
<br />Oc o er 22, 2004
<br />4. CITY AND STATE OF BIRTH 111 not in USA., name country!
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6, DATE OF BIRTH iMonth. Day. Year)
<br />Hazard, Nebraska
<br />(Vrs.l
<br />77
<br />5b. MOS� I DAYS
<br />5c. HOURS MINS.
<br />January 31, 1927 T
<br />7 SOCIAL SECURTIV NUMBER
<br />Be. PLACE OF DEATH
<br />HOSPITAL Inpatient OTHER: 0 Nursing Home
<br />506-22-3861
<br />f
<br />ER Outpatient Residence
<br />8b. FACILITY -Name 11f not institution, give street and
<br />number)
<br />❑
<br />217 W. loth St.
<br />❑ DOA Other /8p6crtyt
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />ee. COUNTY OF DEATH
<br />Grand island
<br />_
<br />Yes ® No []
<br />H411
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9e, CITY, TOWN
<br />OR LOCATION
<br />9d. STREET AND NUMBER /including3p Code)
<br />CITY LIMIT S
<br />Nebraska
<br />Hall
<br />Grand Island
<br />217 W. loth St. 68801
<br />�INSIDE
<br />Nn
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY le.g.. Italian, Mexican, German, atCl
<br />12. ❑ MARRIED ® WIDOWED
<br />13. NAME OF SPOUSE (it wife .give maiden name)
<br />etc.) (specify) White
<br />Specify' American
<br />NEVER DIVORCED
<br />14a. USUAL OCCUPATION (Give kind of work done
<br />during most
<br />M FIRE
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed) _
<br />of working life, even if refired)
<br />Elem ytay or Secondary ID -12) College 11 -4 or s•I
<br />Homemaker
<br />Own Home
<br />JL
<br />18. FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Otto
<br />Krous
<br />Lennie White
<br />18. WAS DECEASED EVER IN U,S, ARMED FORCES?
<br />19a. INFORMANT
<br />- NAME
<br />)Yes. no. or unk.)
<br />(If yes, give war and dates of services)
<br />$ o b C h e l ew s k i
<br />No
<br />I
<br />3b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR I UWN. S I A I L. Dr)
<br />611 West 17th St., Grand Island, Nebraska 68801
<br />E LMER -SIGN E 8 LIC jj 21a. METHOD OF DISPOSITION 2mb.. DATE
<br />,,.,.,� 21C CEMETERY OR CREMATORY NAME
<br />f (,�,� �✓ 41 0 7 Burial El Removal �J�.a�.,a-e 25 2004 + 3akm Nawdal Pa
<br />UNERAL HOME -NAM 21 d. CEMETERY OR CREMATORY LOCATIUN CITY OR TOWN
<br />All Faiths Funeral Home ❑Cremation ❑Donation Grand Island, Nebraska
<br />2b, FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />2929 S. Locust St., Grand Island, Nebraska 68801 _
<br />I uaenCnIATR r411RF (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b). AND (c)I i Interval beM1.,.,.•• .-•..
<br />STATE
<br />PART
<br />(dl A A f /��
<br />DUE TO, OR AS A CON5EQUENCE OF.
<br />(b
<br />DUE TO, OR AS A CONSEQUENCE OFD
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PREGNANCY WALE. PAST 3 MONTHS? 24 A WAS THERE A
<br />PART
<br />II (Ages 10.54) Yes No Yes
<br />URRED
<br />C) / G*I' s
<br />Interval between onset and death
<br />II
<br />25. WAS CASE REFERRED TO MEDICAL
<br />((�� EXAMINER OR CORONERS
<br />No IAI I Yes f l No
<br />2ga. 256. DATE OF INJURY /Mc,, Day. Yc) 25c. HOUR OF INJURY 26d, DESCRIBE HOW INJURY 0C
<br />Accident ❑ Undetermined Lp g M
<br />Suicide ❑ Pending 269. INJURY AT WORK 26f. office 6uQiiding INJURY At hoTe, farm, Street. factory 26g. LOCATION STREET OR R.F D. NO. CITY OR TOWN
<br />Homicide Investigation Yes ❑ No ❑
<br />27a. DATE OF DEATH (Mo., Day. Yr.) 28a. DATE SIGNED (M0.. Day. Yr./ 28b TIME OF DEATH
<br />s October 22, 2004
<br />27b� DATE SIGNED fMd.. Day. Yr./ �,/ 27c. TIME OF DEATH a a r 28C. PRONOUNCED DEAD (Mo.. Day, Ycl 28d. PRONOUNCED DEAD /Hour!
<br />_ss /Ur2G' le 8:00 A. M ��
<br />� 9 27d. To the best of my knowledg th occurred at time, date pl a and due to the S 2Be. On the basis of examination and, investigation, in my Opinion death occurred at
<br />causelsl stated. M ° b the time, date and place and due to the cause(s) stated.
<br />A
<br />(Si nature and Titlel ► ISi nature and Title
<br />29. DID TOBACCO USE CONTRIBUTE YO THE DEATH? 30.2 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />❑ YES NO F-1 UNKNOWN 1:1 YES O E] YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) I7ype or Print)
<br />David Colan, M.D., 729 N1111 Custer Av ., Grand Island Nebraska
<br />32a. REGISTRAR 32b. DATE FILED By REGISTRAR (Ma. Day. YO
<br />jyrm . Nnv 12004
<br />, 1.-z
<br />M
<br />
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