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...� <br />-0— on R <br />NDSWAL C] 1 mom <br />70 <br />rn <br />n n <br />Z > <br />VMF -Neff A/Aa/e,1eMfMt 4MYlNN.IaAi"IwAll <br />f'> <br />A=� <br />❑ 0°A ❑ a..a" o, <br />Park Place Nursing <br />rn <br />CRY. TOM OR LOCAY,DN OF DEATH <br />DUE TO OR ACOIGEGLOCE OF <br />"n <br />m CA <br />CoLwry - m <br />� <br />C-,) U) c <br />ca ) <br />o <br />Igo <br />Ball <br />ga RESIOWN -LTA E <br />! .r <br />IM CITY, Taman <br />LOCATION <br />n Y <br />W. STl@TAIIDNI,L WA AlaU00a rtalN � ONMEANV <br />" PAIMSONS, DEl168TIA <br />ft" 10.3L) Yel - <br />rda w <br />217 W. 18th St.68801 %. Mx❑ <br />Nebraska <br />all <br />Grand island <br />mO <br />14 PACE • 144• TYMee. ftek AnWWO <br />r <br />11. ANCESTRY I0.0 ANNA MYtIFtn Nei <br />rm <br />CD <br />�" "White <br />Iltaa+w <br />Aaeriean <br />"� DAff <br />MARWO <br />Loretta irons <br />+4 U5UA000CUPAUX 9%Vh 4V0W*dW9W"aq/ <br />I 1WDOFl11Mm Nougm <br />2M aN.AIRY AT WOII, <br />15. EDUCATIOM frM! alnMleA <br />Wtoflrq AY ena /lnala <br />CRY on *)Ilk SM7E <br />{❑} <br />ENMNUYrYrreaiR'AMry 1a+1! Gs1eW n�oS -� <br />tHeavy Equipment O <br />erato <br />Construction <br />-.7 <br />-n <br />MIDDLE MST <br />/7 M47NE9 FIRST MIDDLE ■IMItRE <br />(D <br />Chelevski <br />Mar tnszak <br />r <br />W PRDNOINICED MAO Aft LIM, nI <br />11k <br />' NAME <br />T.' <br />C-n <br />O <br />Loretta Chelevski <br />. ?w0A1 LMNT MALLID ADVIES$ <br />,STwW OR R.F.D. NO.. CRY OR TOWN. STATE ZIP/ <br />217 M. 18th St., <br />Grand island <br />Nebraska <br />68801 <br />Z3 <br />4,a. METIIDDaF 09POSKON <br />2,l DATE <br />ft. CEMETSWORC7PALATORY. MIAME <br />❑RU11pra1 <br />may 14 20 1 <br />westlawn Memorial Park <br />Wr-fW"ALMME-NAME v <br />2,d. CEMETERY OR CREMATORY LOCATION <br />UTY OR TOWN SM E <br />All Faiths Funeral <br />Horne <br />��"""°" �DOn"° <br />Gran <br />C.0 <br />z <br />Cl) <br />Lot Fifteen (15), <br />Block <br />One (1), <br />Morris <br />Addition <br />to the <br />City <br />`S5p <br />of Grand Island, <br />Hall County, Nebraska. <br />WHEN THIS COPYCARRWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REGOPa.ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATl&PC1 SI<CTlt31� -NH /CH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ <br />DATE OF ISSUANCE <br />JUN 0 1 2005 200505119 <br />LINCOLN, NEBRASKA HEALTH AIVD_VIMAH SERVA S-'SYS1EM" <br />STA79OFWX WA W. 0, UWA& 1 WCWW&rdAMpIA WMVX PWANXAW411i T <br />V[1'AL OT'ATxnc s 01 05387 <br />CMTHWATB OF DEATH _ -- <br />Paul John <br />Ashton. Nebraska <br />IY T 5 I I,b, MOB <br />ki <br />1 <br />2929 S. Locust St. Grand Island Nebraska <br />-0— on R <br />NDSWAL C] 1 mom <br />506 -26 -9483 <br />Ell dRp.ad ❑ RNdaan <br />VMF -Neff A/Aa/e,1eMfMt 4MYlNN.IaAi"IwAll <br />DUE TO. an AS A CONSEOIIOK'h OF <br />❑ 0°A ❑ a..a" o, <br />Park Place Nursing <br />Hose <br />CRY. TOM OR LOCAY,DN OF DEATH <br />DUE TO OR ACOIGEGLOCE OF <br />w * ~Ami;�Mvw <br />WMDECITY Loom <br />CoLwry - m <br />Grand island, <br />PART 0 F FEMALE. WAS THEFE A <br />ISO <br />V. E) N. ❑ <br />Igo <br />Ball <br />ga RESIOWN -LTA E <br />! .r <br />IM CITY, Taman <br />LOCATION <br />W. STl@TAIIDNI,L WA AlaU00a rtalN � ONMEANV <br />" PAIMSONS, DEl168TIA <br />ft" 10.3L) Yel - <br />rda w <br />217 W. 18th St.68801 %. Mx❑ <br />Nebraska <br />all <br />Grand island <br />2Ic HDIIIOF INAAW <br />14 PACE • 144• TYMee. ftek AnWWO <br />VAW <br />11. ANCESTRY I0.0 ANNA MYtIFtn Nei <br />+R. M MN� ❑ WMO <br />13 MIAME OF 1M41K'E NIIIIY 9F+�r�rryl <br />�" "White <br />Iltaa+w <br />Aaeriean <br />"� DAff <br />MARWO <br />Loretta irons <br />+4 U5UA000CUPAUX 9%Vh 4V0W*dW9W"aq/ <br />I 1WDOFl11Mm Nougm <br />2M aN.AIRY AT WOII, <br />15. EDUCATIOM frM! alnMleA <br />Wtoflrq AY ena /lnala <br />CRY on *)Ilk SM7E <br />{❑} <br />ENMNUYrYrreaiR'AMry 1a+1! Gs1eW n�oS -� <br />tHeavy Equipment O <br />erato <br />Construction <br />121a. <br />14. FATHER • NAME HAFT <br />MIDDLE MST <br />/7 M47NE9 FIRST MIDDLE ■IMItRE <br />Stanle <br />Chelevski <br />Mar tnszak <br />it WAS DECEASED t:vER IN U. lYgRED T <br />W PRDNOINICED MAO Aft LIM, nI <br />11k <br />' NAME <br />Ira. Iq. 41 Wk.I <br />so <br />a vw 4W ad da itftVW <br />Loretta Chelevski <br />. ?w0A1 LMNT MALLID ADVIES$ <br />,STwW OR R.F.D. NO.. CRY OR TOWN. STATE ZIP/ <br />217 M. 18th St., <br />Grand island <br />Nebraska <br />68801 <br />10. MHI- LICEMLgE <br />4,a. METIIDDaF 09POSKON <br />2,l DATE <br />ft. CEMETSWORC7PALATORY. MIAME <br />❑RU11pra1 <br />may 14 20 1 <br />westlawn Memorial Park <br />Wr-fW"ALMME-NAME v <br />2,d. CEMETERY OR CREMATORY LOCATION <br />UTY OR TOWN SM E <br />All Faiths Funeral <br />Horne <br />��"""°" �DOn"° <br />Gran <br />2929 S. Locust St. Grand Island Nebraska <br />a CDIAT CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR law. a ARID Itll <br />IML <br />Mriw*MMw M w CNr <br />PART <br />I'm ISCBMC CEREBRAL VASCM" ACCIDENT <br />0 <br />DUE TO. an AS A CONSEOIIOK'h OF <br />' atNe4411.adAe/deaNlMl <br />IS <br />40 IRS <br />DUE TO OR ACOIGEGLOCE OF <br />w * ~Ami;�Mvw <br />M:{ <br />OTHER 9OIFIGMT CONDITIONL .P.aldlel.w,elewygMadW,IIL.LI IeILILd <br />PART 0 F FEMALE. WAS THEFE A <br />?N AUFOrSY <br />25 ,Mi16CJ4E TIO X <br />PART <br />P1EO/W4CY W TIE PAST 3MONTPIS' <br />" PAIMSONS, DEl168TIA <br />ft" 10.3L) Yel - <br />rda w <br />Yr ri w <br />let <br />M DATE OF EANlRY Aft frY. "I <br />2Ic HDIIIOF INAAW <br />2W. DESCFb HDW r+AIRY OCC)WWED <br />❑ ❑ <br />Acc+tllM WdMlllwltd <br />M <br />Suuae ❑ Prldlq <br />2M aN.AIRY AT WOII, <br />�M ��RY h01�J Mlrla Nr. Mcfn.Y <br />2" LOCAI" STIE#'T UR RF D IFJ <br />CRY on *)Ilk SM7E <br />{❑} <br />YM ❑ Na ❑ <br />rawwn <br />121a. <br />DATEfFOEATH Salo alF nl .I ... <br />1 <br />7M DATESgNED AM7 fry r„ <br />no TIME OF MAT" <br />May 11 2001 a <br />W PRDNOINICED MAO Aft LIM, nI <br />7LR PRONDIIOW0afile I41�e <br />2% DATE SKRMED Aft fW.Y I Xh TIME OF DEATH <br />1 y <br />5/14/2001 4s07 M 9 <br />r <br />?w r <br />P <br />iTd TcddleMrAnTMMAIaal.. tltIII L1X'ar, M Ielle.dMe elltl NAaaella an gale <br />11•� <br />tie Fm..tld/AAI PIeCS andild M,olw dMlaMM IMIIkw•Frla6rr� <br />OYES ❑ NO 1:3 _M_ ❑ YES 0"o ❑ '%n �D <br />31 NAME AND ADOESS OF CERT*W 1PWSICIAIL 'S PHY& NA OR ONATY AVOINEY, 1?xW a P1.e! <br />Lar Hansen 69803 <br />TRIM = VAT€PkLO IY ATM► amp we <br />I &Ad4 !>0.*A. I MAY 17 20 <br />