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<br />4 <br /> <br />, WHEN THIS Copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND-Hf..I/JU.N SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL-lfEt:iNm oii~TH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$r!c;g.SECi1t:JN/VyjPf;!;! IS <br /> <br />:TEU;:=ORYFORWTALRECORDa iJ.iiltni?~ <br />MAR 1 7 1999 20 0 60 3 80 8 Ais/ir~NT S~~TE~g= <br />LINCOLN, NEBRASKA HEALTH ANI1HUMANSERVlClfSliYS"IiiM <br />STATE OF NEBRASKA- DEP ARlMENT OF HEAL11{ AND HUMAN sHRVIc:E$ fl&Mitlf;l.l-/D SlhPORT <br />VITALSTATISnCS'" _:..-." <br />CERTIFICATE OF DEATH - _. ,- <br /> <br />'. DECEDENT - NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br /> <br />LAST <br /> <br />2 SEX <br /> <br />3 OATE OF DEATH (Month, Day Year! <br /> <br />HeIlU Frank <br />4. CITY ANO STATE OF BIRTH Iff not in u.s.A.. name counrry) <br /> <br />February 26, .1999 ...._.. <br />6. DATE OF BIf=llH {MotIt!I. Day YBilr/ <br /> <br />::I Ord Nebras <br />.... 7 SOCIAL SECURTlY NuMBER <br />". <br />~l 508-05-3~__'M_ <br />..1 8b FACilITY. Name (11 nor ,ns,iWtion, give street and (',umbet) <br /> <br />.~~ Tiffany Square Nursing _Center <br />-'ac c',lY, TOWN OR U)C-ATiON OF DEATH <br /> <br />HQSPIT AL. <br /> <br /> 25 1915 <br />0 Inpatienl OTHER kJ NurSing Home <br />D ER OUlpal1enl 0 Aeslocr'lcC <br />0 DOA 0 attle'l (SpeC/lvl <br />COUNTY OF DEATH <br /> <br />Grand <br />9. RESIDENCE - STATE <br /> <br /> <br />ad INSIDE CITY LIMITS <br /> <br />Hall <br />STREET AND NUMBER rfncludi"fJ Zio Code! <br /> <br />ge INSIDE Crtv. LIMITS. <br /> <br />Nebraska <br />10. RACE -(e.g.. Whilc..Blac~, American Indian 11. <br />ole IISpee;1y1 <br />White American <br />14a. USUAL OCCUPATION tGI'.'e/(indofworltdonedl.lringmoS1 t.t::.. ~ 14b. KIND OF BUSINESS INDUSTRY <br />'11 CJI W(Jfklnq fl4J, even il r~ttredJ :-; ...J <br />~ Foreman <br />~ 16 FATHER. NAME FIRST MIDDLE <br /> <br />.!:!I <br />.,. Hynek NMI <br />-11 18, WAS DECEASED EvER IN us. ARMED FORCES? <br />IYes. 110. or unk.l (II yeS ~JlV€! war' ard dales 01 sef'll'icesl <br /> <br />68803 y..1XJ No 0 <br /> <br />13 NAME OF SPOUSl; Iff Wlf8, Qlve maidefl name) <br /> <br />Madalaine Jablonski <br /> <br />15 EDUCATION (SpeCIfy only highest grade completed) <br />Elemenlary or Secondary rO.l~1 ColleQe 11_4 Or ~'I <br />2 <br />MIDDLE MAID~N'SURNAME <br /> <br />NMI <br /> <br />Vanek <br /> <br />19b <br /> <br /> <br />2'a METHOOOFDISPOSITIQN <br /> <br /> <br />i 21C CfMETERy()'Fi"cREM'A"lOH"Y- NAME----'. <br /> <br />March 2 1999 I Grand Island City Cemete~ <br />210 CEMETERY 01=1 CRfMATORY l,OCATION -.-. -.~HfOWN STATE <br /> <br />-:#= 1()3. <br /> <br />Q 8urlal 0 Removal <br /> <br />Kleine Funeral Home <br />22~ FUNERAL HOM~ AoDRESS ISTREn OR RFD'. NO CITy OR TOWN STATE, ZIPI <br /> <br />o Cremalion 0 Donation <br /> <br />Grand Island Nebraska <br /> <br />3213 W. North Front St., Grand Island, Nebraska <br />.....-...- IENTER ONLY ONE CAUSE PER LINE FOR lal,lbl. AND lell <br /> <br />68803 <br /> <br />.~-~~- <br />Interval oetween onset ::Inri (j~a!!) <br /> <br />1.1 C HltlJ...vlc:... L y ~Oc-yn(.. <br />DuE TO. OR AS A CONSEQuENCE OF <br /> <br />J.W;(~/4 <br /> <br />~ 't,,(( <br />Inlerv~ll)etween Onsel and dealll <br /> <br />{bl <br />DUE TO, OR AS A CONSEOuENCE Of <br /> <br />... " '~'~-;m-e-;-\l~;1 belw99n onsel aM death <br /> <br />lei <br />PART OTHER SIGNIFICANT CONlJ!110NS - Conditions conUlbuting \0 1M death but not rel(lled <br /> <br />" ;J Nt u. ~A.n ..., <br /> <br />26. <br /> <br />2Gb nATE OF INJURY (Mo, Day. y, J 26c:: HOuA OF INJuRy <br /> <br /> <br />AS CASF RE~~RRi::-D'lo MEDICAL <br />EXAMINEH OR CORONER? <br /> <br />Yo, n NQ P<a <br /> <br />o Accident 0 Unclelerrruned <br />o SuiCide 0 Pendlnq 269 INJ~JRY A T WORK 261 6ffi~;~lJ?t~i~~,J~~Y (~v;.r-'afm, street factory 269. LOCA nON <br />o Homlc;:jde Invf!SllqClltO!'\ Yes 0 No 0 <br /> <br />STREET OR R.FO. NO <br /> <br />elfy OR TOWN <br /> <br />STAT~ <br /> <br /> <br />(Mo Oil'l y" <br /> <br />26~ DATE SIGNE:D (Mo Dav Yf I <br /> <br />26b TIM!:: OF DEA i-H <br /> <br />.-415'; <br />". ~ ~ !Mo 0., Yo <br />flif~> <br />::i 'Hg .- 'f-B- ~ <br /> <br />~ ~ ~ To Ihe be51 Of my knl)wle 9 dei;l,h Oc::t.urred <br />"I cause(sl staled ~ <br />~ <br />.. . (Signature and Tltlel ,.. _ <br />~ DID TOBACCO USE CONTRIBUTE TO THE DEA TH? <br /> <br />", 0 YES NO 0 UNKNOWN <br /> <br /> <br />sH <br />~~:=>- <br />!~~~ <br />1:"'z <br />o~6 <br />~i5u <br />u ~ <br /> <br />M <br /> <br />28e;, ~RONOUNCED DEAD (Mo Day. Yr.J <br /> <br />2Sd. t='RONOUNCt::O DEAD (HourI <br /> <br />M <br /> <br />M <br /> <br />28e. Or) Iha baSIS 01 exarrllna\lon anQ'Of Investlgallon, In my opUllon death occurred at <br />the lime. date and pla<:e and due 10 the calJsejs) stated. <br /> <br />WAS CONSENT GRANtED" <br /> <br />.... <br /> <br />DYES <br /> <br />NO <br /> <br />(T yp6 or Printl <br /> <br />David R. Colan MD <br />32. REGISTRAR <br /> <br />729 <br /> <br /> <br />ka 68803 <br />32b DATE FILED BY REGISTRAR (Mo., Day. YO <br /> <br /> <br />v <br />