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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 ORIGINALREq~:NF.Il-E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI{)JjfS~'WI1!!;H IS
<br />
<br />:~:~~S::;RY FOR YITAL RECORDS. ~"ZE=E~
<br />I AN 1. !J 2006 2 0 0 6 0 8 4 8i. ASSISTANT' STATE REmstlfAii
<br />LINCOLN, NEBRASKA HEAE..1:H'A.J!D /tUMANSEFJ,VIC/tS
<br />-.
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEi\N~$J~P9~t:) -.,::1,'-.'4 818
<br />CERTIFICATE OF DEATH -">-~,c-;V:q",,:c-
<br />,._-~,-'--- -','-
<br />
<br />1. D~C~D~NT'S.NAM~ (First,
<br />Stanlex_
<br />
<br />Middle,
<br />Clarence
<br />
<br />Lost, Suffix)
<br />Slobaszewski
<br />
<br />2, SEX
<br />Male
<br />
<br />3:DAfE OF DEATH (Mo" Dey, Yr,)
<br />December 31, 2005
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5e, AGE.Last Birthday 5b_ UNDER 1 YEAR
<br />(Yre,) MOS, DAYS
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />5, DAT~ OF BIRTH (Mo" Day, Yr,)
<br />
<br />Rockville, Nebraska
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />507-16-4980
<br />
<br />88
<br />
<br />December 15, 1917
<br />
<br />Bo_ PLACE OF DEATH
<br />l::lO..SEJIAI..: iXi Inpallent
<br />
<br />OlliER: 0 Nursing Home/LTC 0 Hospice Faclllly
<br />
<br />Bb, FACILlTY.NAME (If not institution, give street end number)
<br />
<br />o ~R/Outp.tlent
<br />
<br />o Docedent's Home
<br />
<br />St. Francis Medical Center
<br />
<br />DlXl'.
<br />
<br />o Olher (Specify)
<br />
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Bd, COUNTY OF DEATH
<br />
<br />"
<br />
<br />Grand Island
<br />9a, RESIDENCE-STATE
<br />
<br />Nebraska
<br />
<br />68803
<br />
<br />Hall
<br />
<br />Hall
<br />
<br />
<br />68803
<br />
<br />9g_ INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />9b_ COUNTY
<br />
<br />9d, STR~ET AND NUMB~R
<br />503 West Ave.
<br />
<br />10a_ MARITAL STATUS AT TIME OF DEATH cXMarrled 0 Never Married lOb, NAME OF SPOUSE (First, Middle, Last, Sulflx) If wife, give maiden name,
<br />
<br />DMarrled,bufseparated DWidowed DDivorced DUnknown Doris Michel
<br />
<br />
<br />11, FATHER'S-NAME (Firsf, Middle, Lasl, SUftlx)
<br />Mike Slobaszewski
<br />13, EVER IN U,S, ARMED FORCES? Give dates 01 service il yes, 'r4~:INFORMANT:NAME --- -
<br />(Yes, no, orunk,) No Debra Rouse
<br />- ",.., _.--_._--~~~"_." .-.....-............
<br />
<br />:::~~~~~~:~N
<br />
<br />f2_ MOTHER'S.NAME (First,
<br />Agnes
<br />
<br />Middle, Malden Surname)
<br />Kowolski
<br />
<br />14b_ RELATIONSHIP TO DECEDENT
<br />Daughter
<br />
<br />o Cremation 0 Entombment
<br />
<br />CITY / TOWN
<br />
<br />16c. DATE (Mo_, Day, Yr_ )
<br />
<br />Jan. 4, 2006
<br />
<br />STATE
<br />
<br />15, METHOD OF DISPOSITION
<br />lO Burial U Donallon
<br />
<br />16b, LICENSE NO,
<br />1191
<br />
<br />o Removal 0 Other (Specify)
<br />
<br />Westlawn Memorial Park Cemetery. Grand Island, Nebraska
<br />
<br />18. PART;' Enter the c.tlain.Qf~~ndisBBses, Injuries, or cornpijcations.-tnal directly caused the death. DO NOT enter terminal events such as cardIac arrest,
<br />respiratory arrest, Or venlriculat fibrillation wllhout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on 811n9. Add additional lines il necessary.
<br />
<br />
<br />APPROXiMATE INTERVAL ,
<br />
<br />4 AOI~
<br />oo""'death
<br />
<br />. ~-,,_._,. ~ -.--.-----..-....
<br />17e, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, State)
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road,
<br />
<br />k IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (Flnel ___(a)__YE_l-l'TRICULAR FEBRILLATION DUE TO CORONARY ARTERY.
<br />di..... or condition re.ultlng DUE TO, OR AS A CONSEQUENCE OF:
<br />In death)
<br />
<br />DISEAS
<br />I Onset to death
<br />I
<br />I
<br />I
<br />I onset to deeth
<br />I
<br />I
<br />
<br />Sequentially list conditions, if (b)
<br />any, faadlngtoth..eu.e lI.ted DUE TO, OR AS A CONSEQUENCE OF:
<br />on line e,
<br />Enterthe UNDERLYING CAUSE
<br />(dl.eeee or Injury thet Inltleted (c)
<br />thaavantare.ulllng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />lAST
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditione contrlbullng to the dealh but nol resulting in Ihe underlying caus. given in PART I.
<br />
<br />19, WAS MEDICAL EXA.MINER
<br />..r OR CORONER C~TACTED?
<br />DYES " NO
<br />
<br />o Not pregnanl within pest year
<br />o Pregnant at time 01 death
<br />o Not pregnanl, but pregnanl within 42 days of dealh
<br />o Not pregnant, but pre9nanl43 days 10 1 year before death
<br />o Unknown If pregnant wilhin the past year
<br />
<br />2t._ MI}N~ER OF DEATH
<br />..,..-' i!1 Nalural U Homicide
<br />
<br />21b, IF TRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator /
<br />Dyes b NO
<br />
<br />o Passenger
<br />o Pedestrian
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />o Accld.nlD Pending Investlgetion
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />U Other (Specify)
<br />
<br />(;,) YES UNO
<br />
<br />
<br />22a, DAT~ OF iNJURY (Mo_, Day, Yr.)
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY-At home, farm, street, factory, office building, construction sile, etc_ (Specify)
<br />rn
<br />
<br />
<br />22d, INJURY AT WORK?
<br />
<br />22f, LOCATION OF INJURY. STREET & NUMBER, APT. NO_
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODe
<br />
<br />Z
<br />~:$
<br />118
<br />'Gig!
<br />'ii~~
<br />~l>.Z
<br />"'0
<br />"
<br />H
<br />,2!
<br />..;
<br />
<br />
<br />24a, DATE SIGNED (Mo_, Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />am
<br />
<br />,.,~i:i
<br />.cuz
<br />~u;~
<br />J!~~
<br />Q..CL if:( ~
<br />Ii." ~~
<br />~ffiz
<br />jlz=>
<br />00
<br />~a:O
<br />O~
<br />00
<br />
<br />m
<br />
<br />2005
<br />
<br />240, PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />
<br />It0
<br />
<br />24e. On the basis 01 examlnallon and/or Investigation, in my opinion death occurred at
<br />the time, date and place and due to the causers) staled, (Signatur. and Title) "
<br />
<br />25. D. IDTOBACC~US CONTRIBUTETOT E DEATH? 26a, HAS ORGAN OR TISSUEZATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />..y- ..r- ~
<br />o YES NO 0 PROBABLY 0 UNKNOWN 0 YES NO Not Applicoble if 26a is NO 0 YES U NO
<br />----z7:-;;iAME, TlfLEAND AiiliiiESsOF CiRTIFIER-(PHY$ICiiiN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnt)---------
<br />.\- """DR.wILLIAM J LAWTON, H.D. 2444 W FAIDLEY AVE-;-GIDtNIr ISLAND. NE 68803
<br />
<br />2Ba. REGISTRAR'S SiGNATURE
<br />
<br />
<br />28b_ DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />JAN 6 2006
<br />
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