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<br />
<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, RECOSIHJN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATf$TiCSSEcnCiNFWH!CH IS
<br />
<br />
<br />:;:~~~:RY FOR vrrAL RECOROS. ~;g!aER
<br />2 0 0 6 0 4 3 3 7 t~~St$tANt stArEtl~q.!stflAR
<br />LINCOLN, NEBRASKA fti#Atttf A!JD HUNJA~-~ER.i4CES
<br />
<br />-. -
<br />--..
<br />--
<br />.-
<br />..... .
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAII/Qi'ANOSUPPORT 0 6" 2 2 3 9 3
<br />CERTIFICATE OF DEATH
<br />
<br />J
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR IMo., D.y, Yr.)
<br />
<br />MAR 9 2006
<br />
<br />1. DECEDENT'S.NAME (First,
<br />Margaret
<br />
<br />Lasl,
<br />Kozal
<br />
<br />Sufllx)
<br />
<br />2,SEX
<br />Female
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr,)
<br />Ma:roh 4, 2006
<br />
<br />Middle,
<br />Martha
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />8, DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a, AGE-Laot Blrthd.y 5b. UNDER 1 YEAR
<br />(Yr9,) MOS_ DAYS
<br />84
<br />
<br />November 16,1921
<br />
<br />Nebraska
<br />
<br />B.. PLACE OF OEATH
<br />1:l.Q.Sf1Il;J.:
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />508-12-7055
<br />
<br />o Inpatient
<br />
<br />QI!:l.EB; IX Nursing Home/LTC 0 Ho'plce Facility
<br />
<br />8b, FACILITY. NAME (If not Inotllullon, glv. slreat and number)
<br />
<br />o ER/Qutpa!lent
<br />
<br />o Decedent's Home
<br />
<br />Tiffany Square Care Center
<br />
<br />o lXJI>, 0 Olher (Speolly)
<br />
<br />~ 8d, COUNTY OF DEATH
<br />Hall
<br />
<br />~TOWN
<br />Grand Island
<br />
<br />-l9a, APT, NO ~~~m_'..__
<br />
<br />lOb, NAME OF SPOUSE (Firs!, Middle, Lasl, SUfllx) If wlte, give m.lden n.me,
<br />
<br />9g, INSIDE CITY LIMITS
<br />
<br />a YES 0 NO
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 68803
<br />
<br />19b' COUNTY
<br />Hall
<br />
<br />9<1, STREET AND NUMBER
<br />211 S. Cleburn
<br />
<br />10a, MARITAL STATUS ATTIME OF DEATH 0 Merried aNever Merrled
<br />
<br />[J M.rrled, bul 'eparated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Middle,
<br />
<br />Last,
<br />Kozal
<br />
<br />Sulflx)
<br />
<br />12. MOTHER'S.NAME (Flrsl,
<br />Helen
<br />
<br />Mlddla,
<br />
<br />Malden Surname)
<br />Stempek
<br />
<br />14b, RELATiONSHIP TO DECEDENT
<br />Sister
<br />
<br />13, EVER IN U,S, ARMED FORCES? Glvo d.tes of service II yes, 14a,INFORMANT.NAME
<br />(Yes, no, Drunk.) No Helene Feehan
<br />15, METHOD OF DISPOSITION
<br />KBurlal ODonallon
<br />
<br />
<br />18b, LICENSE NO,
<br />1092
<br />
<br />16c, DATE (Mo" Day, Yr,)
<br />Mar 7, 2006
<br />
<br />STATE
<br />
<br />2k10J
<br />
<br /><.
<br />
<br />OITY I TOWN
<br />
<br />o Cromatlon 0 Entombm.nt
<br />
<br />1Sd, C~METERY, CREMATORY OR OTHER LOCATION
<br />
<br />IJRamoval OOtner(Specily) Westlawn Memorial Park Cemetery Grand Island
<br />
<br />NE
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Stroot, City or Town, Stale)
<br />Curran Funeral Chapel 3005 South Locust Street , Grand Island, NE
<br />
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />1B., PART I, Enler lh. ~Uy,tlll.S--dloeases, InJurle., or compllcallon.--tnat dlraclly caused the dealh, 00 NOT .nt.r termlnalavanla such as cardl.c .rresl,
<br />re'plratory arraOI, or ventricular librlllatlon without showing the etiology, DO NOT ABBREVIATE, En!er only ana causa on a line, Add addltlonalltn.a If necessery,
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />{O Iv!/\, (:l( Vl ( (,,"
<br />
<br />onset to death
<br />
<br />/ Y 0) (V'
<br />
<br />IMMEDIATE CAUSE (Flna'
<br />dlte8sR or condition JetlulUng
<br />In death)
<br />
<br />(a)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 death
<br />
<br />Sequentl.lly 11.1 condltl.n., If
<br />any, le.ding 10 the ,,"u..tI.ted
<br />on IIn...
<br />Enw. the Um)ER~YINQ CAUSE
<br />(dl..... or InJu,\, th.t Inlll.led
<br />thO evento resulllng In death)
<br />LASr
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on5el to death
<br />
<br />(c)
<br />
<br />. DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsat tc death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condlllons contributing to tha daatn but no! r.sulllng In Iha undarlylng c.use given In PART I,
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES IX NO
<br />
<br />rJr..//.}/
<br />
<br />( t{.!I\I.:.,"~,J"'_.
<br />
<br />21 c, WAS AN AUTOPSY PERFORMED?
<br />
<br />o AccldenlO Pandlng Invasllgatlon
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Drlver/Oparalor
<br />
<br />o pa.senger
<br />
<br />o Pedasirlan
<br />
<br />o Other (Spaclfy)
<br />
<br />21d, WERE AUTDPSYFINDINGS AVAILABLETO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />28, IF FEMALE:
<br />~~Ol pragnanl within past yaar
<br />CJ pregnent at lime of dealh
<br />o Not pregnanl, bUI pregnanl wilhin 42 days ot death
<br />o NOI pregnanl, but pregnant 43 days tc 1 year before death
<br />o Un.ncwn if pregnant wltnln tha pa,t year
<br />
<br />21a_ MANNER OF DEATH
<br />a Natural 0 Homicide
<br />
<br />o YES DlNO
<br />
<br />o Suicide 0 Cculd nol be datermlned
<br />
<br />22a, DATE OF INJURY (Mil:, Day, Yr,) . ::]:2b'-:~"OFlNJUR: ""22c,mCFOF lNJURY.Atncma:rajm,slre"I;,actory;-o1m:anulldthq, construGtlon .Ita,-.,c, (~pocifyi-------
<br />
<br />
<br />22d, INJURY ATWORK? 22a. DESCRIBE HOW INJURY OOCURRED
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT NO.
<br />
<br />CrfY/TOWN
<br />
<br />STArE
<br />
<br />ZIP OODE
<br />
<br />tJ;~Di\TEp"FD~ATH (M.O.. Day, Yr,)
<br />3;'-//6(.,-
<br />2~b DATE SIGNED (Mo" Oay, Yr,)
<br />I] -7 (~('r
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />2>-
<br />~~!!;!
<br />1!Ul'"
<br />T,l>g
<br />aa:~~
<br />E"~Z
<br />8fho
<br />1>2"
<br />.000
<br />ea::u
<br />80
<br />
<br />m
<br />
<br />'Tl~;:Ti;:tE OF DEATH
<br />o 0 'j.r II m
<br />
<br />240, PRONOU~CEO DEAD IMo" Day, Yr,) 24d, TIME PRONOUNCED D"AD
<br />m
<br />
<br />249. On thg basts of examination and/or investigation. In my opinion dfJalh occurred at
<br />the time, data and place and due 10 tha caus_(s) sl_ted, (Signalura end Tllla)'"
<br />
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />2Gb, WAS CONSENT GRANTED?
<br />Nol Applicable 1128_ i. NO 0 Y"S a NO
<br />
<br />o YES NO 0 PROBABLY 0 UNKNOWN 0 YES a NO
<br />27, NAME, TlH AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (1\1peor Prinl)
<br />Jeffrey K. King M.D. 729 N. Custer AV, Grand Island, NE 68803
<br />
<br />28a, REGISTRAR'S SiGNATURE
<br />
<br />
<br />I
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