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<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND IlliMA1r$ERVlCES
<br />SYS1E1d, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECOR9_ON FlI..E-WlTH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TlSTl9S,~CTlQI!. Wlitf;H-IS_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~T:'?'j' '(I ~,_,"~)
<br />
<br />DATE OF ISSUANCE ". jO~--oVfVQ" 0'.. ~_
<br />O 20070257 9-: ANt.EYC~~lf:-
<br />JUl 3 2002 ASSI$tNlt,sTATEREGlsrilM{'
<br />LINCOLN, NEBRASKA HEAL TH AND H~N SEFM~~.sTE,!/
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVlCES~INANCE:um SUPPORT
<br />VITAL STATISTICS .... , _- _ __~ -- 0 2
<br />CERTIFICA TE OF DEATH - ,--- -
<br />
<br />08569
<br />
<br />~
<br />u'
<br />~)'
<br />
<br />! Df::U=OENr: NAM"[ ,,-
<br />
<br />FIRSl
<br />
<br />- ..~1i"[)Dli'..
<br />
<br />
<br />Waclaw
<br />
<br />Annischous
<br />
<br />Skarniak
<br />
<br />? SEx -.;3DAY~ OF DEA"T'H'. IMnnm ~li"'; \.:~-;,1r}
<br />
<br />~:D;R~. D.A~' /D~T~~ BI~T~ "MO:OD~v2Yea'l
<br />5c. HOURS MINS 1 1910
<br />'___ August 1 , _______
<br />
<br />LA ~~ :
<br />
<br />Columbus, Nebraska
<br />
<br />Sa AGE:-La~l Birthday
<br />IV,,, 9 1
<br />
<br />
<br />4 CITy AND STAll;: OF BIRTH Ilfnoj"T" USA.. nam6COIJ/'Itryl
<br />
<br />7 SOCIAL SECUATIY NuMOt: H
<br />
<br />8n
<br />
<br />Bb FACILITY. Name
<br />Home:
<br />
<br />~ilf r)Of Ins,i/tJ/iOfJ, give 5tre~f dnri number)
<br />
<br /> l-tOSPITAL 0 Inpatient OTH!:R
<br /> 0 I::R Outpatient
<br /> 0 lJOA
<br />ad INSIDE CITy LIMITS Ae COUmy OF DEA n'l'.
<br /> Ye, [X] No 0 Hall
<br />
<br />o NU(Slnq Home
<br />
<br />[XJ Restaer"\c~
<br />
<br />o Olhe1/S(U?I.II."
<br />
<br />507-12-'8586
<br />
<br />2320 North Huston
<br />
<br />---..--..----
<br />&:; CITY TOWN OR LOCATION OF OEATH
<br />Grand Island
<br />
<br />
<br />/lncfl,)(}ingZ,p Code) p:}~ INSIDE ciTY liMITS
<br />Yes IXJ Nu 0
<br />
<br />9. R..C. SIDEoNCE; - Si-"AIT--i"9."... C.OUNTY
<br />
<br />Nebra~~ Hall
<br />
<br />10 RACE -(e.g.. Whltc~ l31C:id'i. ArTlp.flc::an Indi~n- 11. ANCESTRy.ie.g
<br />fSpE!Cltyf
<br />
<br />Grand
<br />
<br />
<br />Ilalian, MeXican. German. ercl
<br />
<br />elc) (SPflc,tYIWh i t e
<br />
<br />13 NAME OF SF10USE {If wtft~. qlVe mald~fl n.=lme.}
<br />
<br />
<br />FIRST
<br />
<br />Polish
<br />
<br />-. :~ND OF 6USINESS INDuS'RV
<br />
<br />~"elicious Foods
<br />MIDDLE' LASl 11 MOTHER
<br />
<br />Blanche Grabowski
<br />
<br />" ._~
<br />USUAL OCCUPA liON /(;Ive kind of work d()f1e dvring masl
<br />01 Worhl(/.Q lIIe. even II reftfeGl
<br />Maintenance
<br />
<br />15 FDUCA liON (Specify only hlqheSI grade completed)
<br />Elementary Or Secondary 10-121 College 11 -4 or ~1. I
<br />6
<br />
<br />Andrew
<br />
<br />
<br />FIRSI
<br />
<br />MI[)OLE
<br />
<br />MAIDEN SUANAM~
<br />
<br />Tecla
<br />
<br />Zakrzewski
<br />
<br />NA.ME
<br />
<br />Blanche Skarniak
<br />
<br />ISTREET OR RF D NO. CITv OR TOWN. 51 ATE llPI
<br />
<br />NE.
<br />
<br />68803
<br />
<br />o aUrlal 0 Hemoval
<br />
<br />?1b DATE .-.-...--~21c CEMETEAYOR-C~'-NA-Mf.--
<br />
<br />July 19, 2002~ Westlawn Memorial Park
<br />,1d CEMETERy OR CREMATORy LOCAlION CITY OR TOWN~"-' STATe
<br />
<br />:;:'1 a METHOD OF DISPOSITION
<br />
<br />22b. FUNERAL HOME ADDRESS
<br />
<br />o CfenialiOn 0 Donallor
<br />
<br />ISTREET OR R.Fn. NO CITy OR TOWN. STATE, ZIPI
<br />
<br />Grand Island, NE.
<br />
<br />1123 West Second,
<br />
<br />Grand Island, NE.
<br />
<br />68801
<br />
<br />23 IfiMED1A TF. CAUS(
<br />PMn
<br />I
<br />
<br />(f:NTER ONLY ONE C^USC I-'E:R LINE FOR I~I Ill). AND (ell
<br />
<br />.-~[;)I~rViil between O(\S~'!I "'r1(:
<br />
<br />!al
<br />-6UE TO, OR AS A CONSWU"NCE OF
<br />
<br />Natural
<br />
<br />causes
<br />
<br />unknown
<br />
<br />Ibl
<br />DUE TO. OR AS A CONSfOUENCE OF
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />,-
<br />I
<br />I
<br />I
<br />
<br />Interval between onset <1ncl cJ~i-1!1"
<br />
<br />Inler...."lbelwCen On:;U ilrl0 (j~~,.l1l
<br />
<br />lei
<br />OTHER SIGNIFICANT CONOITIONS - CQ()I:!,ItOmi contributing 10 lhe deafh blJl not" relaled
<br />PART
<br />"
<br />
<br />26.
<br />
<br />2Gb DATE OF INJURY (Mo.. Day. Yr.) 26c HOUR QF INJURy
<br />
<br />
<br />25 WAS CAS!: REFERReD ro MLLJICAI
<br />EXAMINER OR CORONFn'l
<br />
<br />~.....
<br />
<br />o Accident 0 Url(jeI9rr'rJlr'led
<br />
<br />o ~-;IJlclde 0 PenCling 26e INJURy AT WORK
<br />o HOllllclde Investigation Yes 0 No 0
<br />:?7a. DA :j:1::. OF DEATH '(Nto Oiiy Yr.)
<br />
<br />269. LO{';.A liON
<br />
<br />SHu:!:T OR n F.D. NO
<br />
<br />CITy OR TOWN
<br />
<br />~-.; 1 A II
<br />
<br />28M. DA H:;: SIGNED (Mo O'=W If I
<br />
<br />28b TIME OF'iJ~'ATH---
<br />
<br />
<br />27b DA TE SIGNED IMo.. O"y Y'I --1270 TIME OF DEATH -
<br />
<br />
<br />27d To the Mst of my k.nowledge death occurred allM lime. dale and place aM duE:!' to lhp.
<br />causelsl stated.
<br />
<br />
<br />_,,", July 24, 2002
<br />
<br />~ ~ ~ ':; 28e. PRONOUNCED DEAlJ IMo Day_ Y'I
<br />!~~5
<br />~~~
<br />() :
<br />(J .-
<br />
<br />2:_}0 pm""
<br />
<br />:;?8d PRONOUNC!:Ll DFAO (HOuri
<br />
<br />M
<br />
<br />4 : 2 0__ P fll",_____
<br />
<br />n dealh OCcurred at
<br />
<br />Co Atty
<br />
<br />o NO
<br />31 NAME .ANO~AODRESS OF CfRTIFIER IPH~YSICIAN, CORONE;R"S PHYSIC1AN OR COUNTY ATTORNEY, I Type ;;;PrintJ
<br />
<br />~ NO
<br />
<br />Jerom E
<br />
<br />Janu1ewicz, Ha1i County Atty,
<br />
<br />~!J ;J ~6~v
<br />
<br />117
<br />
<br />E
<br />
<br />1st; Grand Island, NE
<br />
<br />68801
<br />
<br />3?a REGIS 1 HAR
<br />
<br />32b DATE FIU=:O 6Y REGISTRAH (Mo.,Oay. Yr,
<br />
<br />JUL 2 9 2002
<br />
<br />(;(~ t 6-[ le ~ f+d dt~(itf;U -iD IJJt4t l tl.~}/l, iA\..
<br />I~J ttL I (!-iJ U~{ ~h )...) L.
<br />
<br />i....o-t ~1 5/oJ- /3
<br />/11 __.. (] Vli//)d ,~sl dfll,
<br />v <( Jr/,(J -
<br />
|