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<br />STATE OF NEBRASKA
<br />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 ORIGIfJ.&LRECORO ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlS!lCSSfttlCJJkWHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . .._ --=:~~ :-,j-:~J~7F-~~
<br />
<br />~re~~~~ ~~~
<br />
<br />SEP 1 6 Z005 20051203 6 l'ssf$T!NiS:rAf~I1EiJfirfRAR
<br />LINCOLN, NESRASKA . HEAUXAND 'HfJMAn stRVtCES
<br />':,<.-- -1:}It~~/ ~-~ /~
<br />
<br />STATE OF NEBRASKA- DEPARTMENT. OF HEALTH AND HUMAN SERVICES FINANc:€ANOSQPPDRi6's . 1. O. 162
<br />CE:~TIFICATE OF DEATH ... '_~-_ .. . ____
<br />
<br />~
<br />
<br />
<br />1, DECEDENT'S-NAME (Firsl,
<br />Frederick
<br />
<br />Middle,
<br />
<br />Rawson
<br />
<br />LOSI,
<br />
<br />Suflix)
<br />
<br />2, SEX
<br />Male
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />50. AGE. Last Birlhday 5b. UNDER 1 YEAR
<br />(Yrs,) MOS. DAYS
<br />87
<br />
<br />50, UNDER 1 DAY
<br />-., -----
<br />HOURS MINS,
<br />
<br />3. OATE OF DEATH (Mo., Day, Yr.)
<br />
<br />S tE'!JJbe..r..,tl_, 2005
<br />6, DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />S_alak
<br />
<br />Schuyler. Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />October 15. 1917
<br />
<br />8a. PLACE OF DEATH
<br />
<br />507_::-10-9324
<br />8b. FACILITY-NAME (If not institution, give slreel and number)
<br />
<br />llil5f1IAL:
<br />
<br />o Inpatienl
<br />
<br />QII:lEB: )g{Nurslng Home/LTC 0 Hospice Facility
<br />
<br />o ER/Outpatienl
<br />
<br />o Decedent's Home
<br />
<br />Grand Island Veterans Hone
<br />
<br />0=
<br />
<br />o Other (Speolly)___.,
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />-L~~~l
<br />
<br />8d, COUNTY OF DEATH
<br />
<br />__~a!..1~S:9_~ty
<br />
<br />1221 N. Sherman AV
<br />n___ ____....
<br />lOa, MARITAL STATUS AT TIME OF DEATH iXMarriod 0 Never Married
<br />
<br />gc, CITY OR TOWN
<br />Grand Island
<br />
<br />Je APT N~ 9f,~I~~O~~
<br />
<br />lOb, NAME OF SPOUSE (First, Middle, Last, Sulllx) If wlfa, give maiden name,
<br />
<br />gg, INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />o Divorced 0 Unknown
<br />
<br />Vivian M. Harvey
<br />
<br />11. FATHER'S.NAME (First, Middle,
<br />Rudolph W. Salak
<br />
<br />Lasl,
<br />
<br />SUffix)
<br />
<br />12, MOTHER'S-NAME (First,
<br />Sylvia
<br />
<br />Mlddla,
<br />
<br />Maiden Surname)
<br />Buck
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of service If yes, 14a.INFORMANT.NAME
<br />(Yel.ro~r"nk,) 11-4-41toll-12"..45 Vivian Salak
<br />15, :::~a~ OF DI:~:~::I:~ 16~ "BALM~R-SI~NATU~E//11 .1M oJ
<br />.J L J,~~.eJC!)----L4. ~~
<br />
<br />o Cremation 0 Entombmenl I 6d. C;~Y, CREMATOR/OR OTHER LOCATION
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />~::--~
<br />
<br />CITY /TOWN
<br />
<br />I 8c. DATE (Mo" Day, Yr, )
<br />
<br />S~p_~ember 12. 2005
<br />STATE
<br />
<br />o Romoval 0 Olhar (Specify)
<br />
<br />Elmwood Cemetery
<br />
<br />St. Paul. Nebraska
<br />
<br />...-----
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clly or Town, Slate)
<br />Curran Funeral Chapel 3005 S. Locust St. Grand Island. Nebraska
<br />
<br />17b, Zip Code
<br />
<br />68801
<br />
<br />PART l. Entar the chain of AvenlF.i--dlseasas, InJuries, or compllcallM5--thal directly caused the death. DO NOT enler terminal Avent" such as cardiac Arrest,
<br />respiratory arresl, or ventricular fibrillation wlthoul showing' Ihe ellology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addltlonallln8s if necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset 10 death
<br />
<br />IMMEDIATE CAUSE (Flnat __~~~~~iq,pu~ Arrest
<br />disease or conditlonresultlng DUE TO, OR AS A CONSEQUENCE OF:
<br />In death)
<br />
<br />Soquontlallylist condlllons,It (b) Congestive Heart Failure
<br />
<br />anY,leadlngtothecausellsted -----oiJE-TO, OR AS A CONSEQUENCE OF:------
<br />on linea.
<br />Enter the UNDERLYING CAUSE
<br />(dll!i8!S8 or Injury that Initiated (c)
<br />thaevents resulting In death) DUE TO, OR AS A CONSEOUENCE OF:
<br />LAST
<br />
<br />- 0 -
<br />
<br />I onset 10 death
<br />I
<br />I 2 Years
<br />r.'.__.'~'. ...._...._.____.....
<br />I onset 10 death
<br />
<br />(d)
<br />
<br />I
<br />I
<br />
<br />_.~.___L_______._______
<br />! onset to death
<br />I
<br />I
<br />
<br />PART II, OTHER SIGNIFICANT CONDITIONS-Conditions conlrlbulinglo the dealh but not resulting In the underlying causa given In PART I,
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES XX. NO
<br />
<br />Atrial Fibrillation
<br />
<br />20, IF FEMALE:
<br />
<br />21 a. MANNER OF DEATH
<br />Xl Naturel U Homicide
<br />
<br />21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Drlver/Operalor
<br />
<br />D. Not pregnant wilhln pasl year
<br />U PregnatH al time of dealh
<br />o NOI pregnanl, but pregnant wilhln 42 day' of death
<br />o Nol pregnanl, but pregnanl43 days 10 1 year before daalh
<br />o Unknown il prognant within the past year
<br />
<br />o AccidentD Pending Investigation
<br />
<br />D Passenger
<br />o Pedestrian
<br />o Other (Speci/y)
<br />
<br />o YES
<br />
<br />iXNO
<br />
<br />o Suicide 0 Could nol be determined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />22a, DAlE OF INJURY (Mo" Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, farm, street, factory, office building, construction site, elc. (SpeCify)
<br />m
<br />
<br />o YES 0 NO
<br />
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22f, LOCATION OF INJURY - STREET & NUMBER, APT, NO.
<br />
<br />CITYfTOWN
<br />
<br />SlIIrE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />SeI2~~er B, ~Q_Q?_
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />
<br />>:iiU
<br />..Quz
<br />i~~
<br />~fiC(~
<br />H1::~
<br />uw2:
<br />.!lZ=>
<br />00
<br />~a:u
<br />8l;
<br />
<br />m
<br />
<br />230, TIME OF DEATH
<br />7:46 A. m
<br />
<br />240, PRONOUNCED DEAD (Mo" Day, Yr,)
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d, To the b,~sl 01 my knowledge, dealh occurred at Ihe lime, dale and place
<br />and clio the ~,~us\,(s) ~tated. (Sigpature ,and Title) T
<br />
<br />" llllavv (u1dPJr.4;;f
<br />
<br />26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />24e. On the basis of examination and/or Invesllgallon, In my opinion death occurrad al
<br />Ihe lime, dale and place and due 10 the causers) staled. (Signalure and Tille) T
<br />
<br />25,010 TOBACCO USE CONTRIBUTE TO THE OEATH?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />o YES XKNeJ. 0 PROBABLY 0 UNKNOWN 0 YES .... _._ ~ _,..._IllI,_~~. .___ Not Applicable II 26a Is ~.9_...9_~ES 0 NO
<br />-- 27. NAME, TITLE AND ADDRESS OF CERTIFiER (pHYSICIAN, CORONER'S PHYSICiAN OR COUNTY ATTORNEY) (Type or prlnl)
<br />Sheridan T. Anderson, M.D., Gr d Island yterans Horre, Grand Island, NE 68803
<br />
<br />28a, REGISTRAR'S SIGNATURE 28b, DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />
<br />SEP 1 5 2005
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