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<br />STATE OF NEBRASKA
<br />
<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 ORIGINAL RECORDDN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlS-gesJi~eTiJjN,=-:wtlICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _i?-_ i-(-'~-;:;T~i.-::_
<br />
<br />
<br />DA;~~F;SStz~C~ ffl:~~-cAR
<br />2 0 0 6 0 3 9 8 6 4$s!s,TA'NTS"ATEREGjST~;'R
<br />LINCOLN, NEBRASKA . H~fTft.~Nf~U~~N9FW!tjES
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<br />~:-:. -=-:.~ .._=-~::,~-=:i:::':.
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<br />STATE OF NEBRASKA - DEPAR~~~;rF~~%;~N~~U~~AT~~_~c~s F'~~~~-~A_N_~S~~~~65.. . 08_~ I~_
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<br />DECEDENT'S-NAME (First, Middle, Last, Sullix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />__________ Willi":.1J!. Matt Fila Male Au ust ll. 2005
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Bee. Nebraska
<br />
<br />Se. AGE-Lest Blrthdey 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />84
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Dey, Yr.)
<br />
<br />February 24. 1921
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-20-1635
<br />
<br />ee. PLACE OF DEATH
<br />1::lillil'lIAl.:
<br />
<br />Q Inpellenl
<br />
<br />QIltiJ: U Nursing HomelLTC U Hcsplce Feclllty
<br />
<br />FACILITY-NAME (If tlol Inslltution, giv~ ~1reAI and numher)
<br />
<br />Q ERIOutpatiant
<br />
<br />Xl Decedent's Horne
<br />
<br />~
<br />
<br />224 East 17th Street
<br />
<br />Q [llI\ Q Other (Specifyl".________.___~____ ________._
<br />
<br />""-1 - - . --- --- ---.------
<br />ed COUNTY OF DEATH
<br />
<br />
<br />Hall
<br />_ _ ___ ~ _ r r__
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />Grand Island 68801
<br />
<br />Hall
<br />
<br />
<br />9g. INSIDE CITY LIMtTS
<br />
<br />1lO YES Q NO
<br />
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />
<br />9b. COUNTY
<br />
<br />Street
<br />
<br />Q Nevor Married lOb. NAME OF SPOUSE (First, Middle, Last, Sullix) If wito, givo maidan nama.
<br />
<br />Dorothy Kowalewski
<br />
<br />._____ Middle, Fi~:t'S~:=tMOTHE-;.S-NA~~:;st,
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates ot service If yes. 14a.INFORMANT-NAME
<br />~'l!:p,o,o"mk) 8/24/1942-10/19/194 Dorothy Fila
<br />
<br />o Divorced 0 Unknown
<br />
<br />Middla,
<br />
<br />Maidon Surnama)
<br />
<br />Hamata
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />QBurial
<br />
<br />o Donalion
<br />
<br />16a. EMBALMER-SIGNATURE
<br />
<br />Not Embalmed
<br />
<br />l6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />___J~~~.~~~_~::_N:.
<br />
<br />CITY / TOWN
<br />
<br />16c. DATE (Mo., Dey, Yr.)
<br />____August 12, 2005
<br />STATE
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />01 Cremation Q Entombment
<br />
<br />CJ Removal [J Other (Specify)
<br />
<br />Westlawn Memorial Park Crematory Grand Island, NE.
<br />
<br />PART I. Enter the chaIn of evenls-.dlseases, inJurIes, or complicallonsuthal dlreclly caused the death. DO NOT enler terminal events such as cardiac arrest.
<br />respiratory arrest, or ventricular ribrillalion without showing the etiology. DO NOT A8BREVIATE. Enter onry one cause on a line. Add addilionallines If nBcessary.
<br />
<br />
<br />I
<br />
<br />: onsol.ArW J
<br />:~
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<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Straot, City or Town, Stato)
<br />Livingston-Sondermann F.H. 601 N. Webb
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<br />tMMEDtATE~E; /J
<br />X "r( ,- I '
<br />IMMEDIATE CAUSE (Flnel .~a!_...______~_ q .f!!~~_L~______9!!1-__S~!!. c:__~ cer
<br />disease or condition resultln9 DUE TO, OR AS A C~SEQUENCE OF:
<br />In d..th) )(
<br />
<br />---
<br />
<br />I onset 10 death
<br />X.
<br />
<br />Sequentlelly list conditions, II (b)
<br />any, t..dlngtoth.c.u..II.t.d DUE TO, OR AS A CONSEQUENCE OF:
<br />on line 8. ___'
<br />Enter Ihe UNDERLYING CAUSE
<br />(dl..... or Injury that Inltlat.d (cl
<br />lheeven19r.suhlng Indea1h) DUE TO, OR AS A CONSEOUENCE OF:
<br />lAST
<br />
<br />onsst to death
<br />
<br />on.el to daath
<br />
<br />(d)
<br />
<br />)';
<br />
<br />. - --.----r;9. WAS MEDICAL EXAMtNER
<br />OR CORONER CONTACTED?
<br />Q YES W"'No
<br />-.----- - ',.'.,. .'., ,. ,. ~_..,.._-'_.,----
<br />21 b.IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMED?
<br />Q Drlver/Operetor
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<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condlllons oontrlbullng 10 the death but nol resulting In the underlying cau,e given In PART I.
<br />
<br />20. IF FEMALE:
<br />Q Not pragnant within pasl yaar
<br />q Pregnant at lime of death
<br />o NOI pregnant, but pregnant within 42 day' 01 death
<br />o Not pregnant, but pregnant 43 days 10 1 year before death
<br />o Unknown If pregnant wllhtn Ihe past year
<br />
<br />21~: MAN.PJER OF DEATH
<br />X ~a1ural Q Homicide
<br />
<br />Q Accld,nlQ Pending Inve"lgetlon
<br />q Suicide 0 Could not be determined
<br />
<br />o Passenger
<br />Q Padastrlan
<br />Q Other (Specify)
<br />
<br />X Q YES
<br />
<br />b1;(;
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />.I{ COMPLETE CAUSE OF DEATH?
<br />Q YES ~
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<br />22a. DATE OF INJURY (Mo., Day,-Yr.)
<br />
<br />22b. TIME OF INJURY .. "220. PLACE OF iNjURY:';:! home, farm, str'eet, laclory, office building, construction slle, etc. (Speclly)
<br />
<br />m
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<br />22a. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
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<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYIrOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
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<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
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<br />
<br />:.on:;
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<br />'Cu;~
<br />HI:
<br />c:&.Q,.4J:~
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<br />8ffi~0
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<br />00
<br />~rE.U
<br />o~
<br />00
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<br />24C. PRONOUNCED DEAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
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<br />24,. On the basis ot exemlnatlon and/or Investigation, In my opinion death occurred at
<br />Ihe time, dete and piece and dua to the causo(,) staled. (Slgnaturo and Tillo ) "
<br />
<br />26a. HAS ORGAN OR TtSSUE DONATION BEEN CONSIDERED' 26b. WAS CONSENT GRANTED?
<br />
<br />
<br />[j,.N6 ~ot Applloable If 26a Is NO Q YES
<br />
<br />AUG 16 2005
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