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WHEN THIS 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 ORIGINAL RECl3MONFILE' WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISIXS_SECT" WIICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE ,�r 0 N'
<br />oLv 56079 i4NLI _$ .6WkR
<br />12/6/2004 4sslsTANT- sT^TE FRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUNAff SERWO`OY-STOM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SIMVICESryls aNCfi AND SUMRT
<br />VITAL STATISTICS n
<br />CERTIFICATE OF DEATH 0 4 13117
<br />1. DECEDENT - NAME FIRST
<br />MIDDLE LAST
<br />2. SEX
<br />3, DATE OF DEATH /Month. Day. Year)
<br />Lucile
<br />B. Damratowski
<br />female
<br />November 16 2004
<br />UNDER 1 DAY
<br />16, DATE OF BIRTH /Month, Day. Year)
<br />4. CITY AND STATE OF 81R 7H (lt not to U.S.A.. name country) 5a. AGE - Last Birthday UNDER 1 YEAR
<br />EXAMINER OR CORONER?
<br />(YrsJ 51p. MOS, I DAYS
<br />(Ages 10 -54) Yes Na
<br />5c. HOURS' MINS.
<br />Rolette,, Northi:Dakota
<br />69 I
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />December 16 1934
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />506 -40-1857
<br />HOSPITAL: ❑ Inpatient OTHER_. © Nursing Home
<br />Bb. FACILITY - Name /tlrot insfirudw, give street and number) ❑ ER Outpatient ❑ Residence
<br />Cloverlodge Care Center
<br />❑ DOA ❑ Other(Specdvi
<br />8e. CITY TOWN OR LOCATION OF DEATH
<br />ad. INSIDE CITY LIMITS fie. COUNTY OF DEATH
<br />St. Edward
<br />Yes R] No ❑ Boone
<br />9a. RESIDENCE - STATE
<br />gb. COUNTY
<br />❑ ❑
<br />9c. CI1 Y, TOWN OR LOCATION
<br />9tl. STREET AND NUMBER /Including Zip Codel
<br />9e. INSIDE CITY i.IMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />116 N. Beachwood, 68803
<br />Yes [� No ❑
<br />10. RACE - (e,g., White. Blank. American Indian.
<br />11. ANCESTRY (e.g., Italian, Mexican, German, etc(
<br />12. [K MARRIED
<br />❑ WIDOWED
<br />13. NAME OF SPOUSE //( wife. give maiden name)
<br />etc.( ISpecily)
<br />(Specify/
<br />unknown
<br />�J NEVER
<br />EIMARHIEQ
<br />DIVORCED
<br />Lawrence Damratowski
<br />white
<br />28d. PRONOUNCED DEAD (Hour)
<br />p yJ
<br />goy
<br />14a. USUALOCCUPATION (Give kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />27d. To the best of my knowledge, death occurred at the time, date and place and due to the
<br />15. EDUCATION (Specify only highestgrade completed(
<br />Elementary or Secondary I0 -12) College (1 -4 or 5 -I
<br />of working life, even if retired)..
<br />° ° the time, date and place and due to the cause(s) stated.
<br />Secretary
<br />ISi nature and Title
<br />Retail. ApPliaoce Store
<br />LL12
<br />16. FATHER • NAME FIRST MIDDLE LAST
<br />17. MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Wane
<br />Stanton
<br />AL If6"2 LZ:'����r 51�. t. ��c���rel A)c 6S'6 r/ �
<br />LaMena Plane
<br />.18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />)J*�k I
<br />19a. INFORMANT - NAME
<br />,
<br />(Yes, no. or unk,) pf yes, give war and dates of services(
<br />no
<br />Lawrence
<br />Damratowski
<br />19b. INFORMANT MAILING ADDRESS
<br />(STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP)
<br />6MER Beachwood Gr
<br />land
<br />20. EM
<br />2 a METHOD OF DISPOSITION
<br />216. DATE
<br />21c.
<br />CEMETERY OR CREMATORY NAME
<br />'' G,t-,
<br />-
<br />Burial ❑ Removal
<br />r�
<br />11/19
<br />r-�
<br />V4
<br />St. Michael's Catholic
<br />22a FU 'L HOME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OH TOWN STATE
<br />- eVander Funeral Home
<br />❑Cremation ❑ Ponauon
<br />Albion Nebraska
<br />22b, FUNERAL HOME ADDRESS (STREET OR R.F.D. NO,.
<br />CITY OR TOWN. STATE, ZIP)
<br />308 A. Marengo St., Albion, NE 68620
<br />123. iMMEDI A CAUSE TENTER ONLY ONE CAUSE PER LINE I0H lal. 11)), ANU loll merval oeween onset ano Peam PART (a'Q
<br />DUE TO, OR AS A CONSEQUENCE OF ✓ Interval between onset and death
<br />(b) 5 y"S
<br />DU� TO, OR AS A CON OUENCE OF Interval between onset and death
<br />_ l 0., 1 f7 1711 .
<br />(c) v • L - . , (-i v r. - r, �_. - r ,
<br />- , _
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />I IF FEMALE. WA$ THERE A
<br />2a AUTOPSY
<br />25 . WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MgNTHS?
<br />EXAMINER OR CORONER?
<br />1
<br />(Ages 10 -54) Yes Na
<br />Yes 0 No
<br />yes Np
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW WJJRY OCCURRED
<br />Accident ❑ Undetermined
<br />M
<br />❑❑
<br />Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />jetRY - At , farm. street. factory
<br />26g. LOCATION STREET OR R, F. D, NO. CITY OR TOWN STATE
<br />El Homicide Inveeagaadb
<br />❑ ❑
<br />7peiceCtbui�,Fn'i
<br />Yes No
<br />272. DATE OF DEATH (Mo.. Oay Yr.)
<br />28a. DATE SIGNED iMo.. Oay. Yrl
<br />28b TIME OF DEATH
<br />AAOVe_,�tw 161
<br />� w
<br />M
<br />y
<br />27b. DATE SIGNED (Mo.. Day. Yr)
<br />27c. TIME OF DEATH
<br />i
<br />28c. PRONOUNCED DEAD (Mo.. Day. Yr.)
<br />28d. PRONOUNCED DEAD (Hour)
<br />p yJ
<br />goy
<br />;g€
<br />27d. To the best of my knowledge, death occurred at the time, date and place and due to the
<br />2 c4 28e. On the basis of examination and, or investigation, in my opinion death noeurred at
<br />~
<br />I
<br />causels) stated.
<br />° ° the time, date and place and due to the cause(s) stated.
<br />_
<br />(Signature and 7it10) ► � 'V
<br />ISi nature and Title
<br />29. OIO TOBACCO USE CONTRIBUTE TO THE DEAT
<br />0. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES © NO UNKNOWN
<br />YES ❑ NO
<br />❑ YES r�J2 NO
<br />31. NAME AND ADDRESS Or CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type ovRnhii
<br />AL If6"2 LZ:'����r 51�. t. ��c���rel A)c 6S'6 r/ �
<br />32a. REGISTRAR
<br />�17.
<br />DATE FILED BY REGISTRAR 11i 11i Da . Yc)
<br />)J*�k I
<br />Cade b.9 6.��4
<br />
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