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<br />STATE OF NEBRASKA
<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 ORIG/~ 'REC~D G/Jf;FlL.E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATfSTlCSSECTlql)!:WIHIC/-:,IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ..:.~t'...--..."'" . ',. co.' J=li::.........; -..:i~,
<br />
<br />DATE OF ISSUANCE ~ ,,_ ._ '" KI. "',.,~~.~~
<br />.: f-X' TANLEr s1 COOPER
<br />FE B 2 6 2.007 2 0 0 7 0 2 913 'ASSISTANT sTirfE" ~~/$rRAR
<br />LINCOLN, NEBRASKA It,EALTH ~1JIP'j!!lM'isE.1iYICES
<br />. ,., - .-.r.::.:--.;-' -.::.:~.-.~.:::,~
<br />
<br />-:
<br />
<br />
<br />STATE OF NEBAASKA- DEPAA~~~~rF~~~;~N~~U~~N:~~VICES FINANCE AND SUPP(Jl221~
<br />-1~-~~CEDENn.N~~~_f;:.~~ .;:d~.ix' -- La~io'lbasa '~.IIX.) .-----. 2'..S:~e . ....9.. ~:~:O..U.F.~~~j (;o;.D~,~r~L
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE.Lasl Birthday 5b. UNDER 1 YEAR 5c, UNDER 1 DAY 6, DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />~enoa, Nebraska___. _~s;9 _Mr _HOURS [:NS May l!_, 1927
<br />
<br />=fa PLACE OF DEATH
<br />506-26-7~~ ____ tlQWIAL.:!p Inpallenl
<br />FACILlTY.NAME (If nol InstitutIOn, give sfroot end numbor) LJ ER/Oulpallont
<br />
<br />Bryan LGH Med~.cal Center Ea~_ _. ~._CO'.
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />QlliEfj:
<br />
<br />o Nursing Home/LTC LJ Hospice Facility
<br />
<br />I:} Decedent's Home
<br />
<br />o Other (Sp.clly)___
<br />
<br />ad. COUNTY OF DEATH
<br />Lincoln Lancaster
<br />
<br />.9aRESI;E:_~E;;:ka--- _1~C::7l - .... _~~::~OW~~-~~~d. . ------
<br />9dSTA4;A64NU~~~~ona Avenue --='- ...- .____lge,APT,NOJ9f~I~~~;
<br />
<br />o Navar Married lOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, giv. maldon neme,
<br />
<br />~.- gg. INSIDE CI'TyLIMITS
<br />
<br />XXYES [) NO
<br />. --..".''''.--. --
<br />
<br />o Marriflo, but separated 0 Widowed 0 DIvorced 0 Unknown
<br />
<br />Florence "Polly" Krueger
<br />
<br />11. FATHER'S.NAME (First,' Middle,
<br />Frank A. Kiolbasa
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />'2. MOTHER'S.NAME (Flrsl, Middle,
<br />Barbara Uzendowski
<br />
<br />Maiden Surname)
<br />
<br />, 3, EVER IN U,S, ARMED FORCES? Give datos of service II yes. 14a,INFORMANT.NAME
<br />(Yos,no,orunk) Yes 8/21/45-8/15/46
<br />
<br />14b. RELATIONSHiP TO DECEDENT
<br />
<br />aurlal
<br />
<br />o Donation
<br />
<br />
<br />16a. EMBALMER.SIGNATURE
<br />
<br />ce. "Polly" Kiolbasa"
<br />I :I- 16b LICENSE NO.
<br />13~,1
<br />
<br />OCATION CITY / TOWN
<br />
<br />Wi:fe
<br />16c. DATE (Mo" Day, Y,- )
<br />
<br />.,februa~y 14. 2QOL
<br />STATE
<br />
<br />15, METHOD OF DISPOSITION
<br />
<br />o Cremallon U Enlombment
<br />
<br />o Removal 0 Olher (Specify)
<br />.__.__ ... Grand_.Island City Cemetery, Grand Island
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Str.ot, City orTown, Stalo)
<br />
<br />Livingston-Sondermann Funeral Home, 601 No.
<br />
<br />Nebraska
<br />
<br />
<br />18. PAnT t. Enter lhe ~hain Qf evenl.!i.--diseasBs, inJuries, or cornplicatlons--thal directly caused the death. DO NOT enter terminal evenls such as cardiac arresl,
<br />rBsplralory arrest, or ventricular fibrillation wlthoulshowing the etiology. DO NOT A8BREVIATE, Enter only ona cause on a line. Add additional lines If necessary,
<br />
<br />~
<br />CI.
<br />E.
<br />8
<br />
<br />1
<br />I ~setto d.ath
<br />I
<br />.~IQ ItS- flf"1
<br />
<br />I Ons81 to death
<br />I
<br />1
<br />1
<br />I onsel to dealh
<br />1
<br />1
<br />-------L. __. __.
<br />I onsot to dealh
<br />1
<br />.1
<br />
<br />~ Il<W""""C~"""
<br />
<br />OR CORONER CONTACTED?
<br />
<br />>> YES 0 NO
<br />
<br />20 'IF FEMALE' . I~ '^"'" OC ~'m '" ';m""",ffi~O"~';"l!1' w;"","m"","~""
<br />ilYNalural U HomicIdE! 0 Dnver/Operator }(r
<br />U Not pr.gnant within past yoar
<br />o passonger 0 YES NO
<br />o Pregnant altime of doalh 0 AccldenlO Pendrng Investigation
<br />o Pedestrian -
<br />U ..NOI..progn,nt, bU..t p.r.e~nanl wllllrn 4.. 2 d....a...y. sol dealh. U surcr.de 0 COU.ld not be determinOd.. U I jlli WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />U NOI pregnant, bUI pregnall143 days 10 1 year bofore dealll I - Other (Specify) COMPLET" CAUS F DEATH?
<br />
<br />o Unknown II pr.gnant wllhln Ihe past year ~ _ _.__ _ 0 YES NO
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<br />22;DAT~ OF INJURY '(Me" Dey, yr:) 'rME'OF INJUR: . r 22c~ PLACE OF INjURY-AI hom., 'farm, Slreel, factory, office building, construction site, .t~-(SP~Clly)
<br />
<br />
<br />--22d'iNJURY ATlVORK?]2;'OESCRIBE HOWINJURY OCCURRED-- -. '-. ... .____.u .. .
<br />o YES U NO
<br />....----
<br />221. LOCATION OF IN,JURY. STREET & NUMBER, APT. NO. CITYIfOWN
<br />
<br />IMMEDIATE CAUSE;
<br />
<br />fMMEDIATE CAUSE (Fin.'
<br />disease or eondlUon resulting
<br />In death)
<br />
<br />~_.,~~V_~~l:\+)'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />.~J;T.
<br />
<br />Sequentially list condlllons, If (b)
<br />any, leading to the cause IIslod DUET6;6R AS A CONS~QUENCE OF;'
<br />on line a.
<br />Enter the UNDERLYfNG CAUSE
<br />(diseese or injury thotlnlllsted (e)
<br />the events resulllng in doath) ----OUET-O~ OR AS A CONSEQUENCE OF:'
<br />lAST
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.Condillons contributing to th. death but not rosulting In the undorlying cause given in PART I.
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<br />"
<br />
<br />
<br />STI\fE
<br />
<br />ZIP CODE
<br />
<br />-;r'-- -...-. --
<br />.:::T:~F DEATH _(MO,_~ay, Yr,) ~lq j)C(JL _
<br />
<br />~ DATE SI NED ( D" Day, Yr.) )gc, TI~~ OF .ot~JI
<br />10: '16/1 m
<br />
<br />~,TO Ille best of my knowtedg., doafll occurred at the time, data and place
<br />and due totho cause(s) stated. (Signature and Tillo) l'
<br />
<br />24a. DATE SIGNED (Mo" Dey, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />>j~
<br />.o2cr
<br />'ll"'o
<br />'!l!;:l=,.
<br />'5.ll..4:r:..J
<br />~C::i:~
<br />u"'z
<br />~z'"
<br />.000
<br />~a::U
<br />o~
<br />uo
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIM" PRONOUNCED DEAD
<br />m
<br />
<br />24a, On the basis of Bxaminallon and/or investigation. In my opinion death occurred at
<br />tho time, dale end plac. and due 10 Ih. causo(s) staled. (Signature and Tille) l'
<br />
<br />2Bb. DATE FIL.ED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />FEB 2 6 Z007
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