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<br />.-
<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 COPYOF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlCSc~TION, WHICH IS
<br />
<br />
<br />::~;~~7;;:;YFOR:::E;~:6 6 3 ~~:
<br />
<br />LINCOLN, NEBRASKA !,EALTH AND iJiJMANSEf?]ICES
<br />STA11IOF liEIlIuu.DlPAIlnen'OI' ISALm AM)fIUMAN _VIt1l.f-~... ..==~
<br />CER~~lriF~TH -'''<::,-,-_-:---c..v~'- 04853
<br />
<br />FlAST lAS ~ so -- 13 oiiOF-ii(..IH ,_ Ooy v_,
<br />
<br />t. fllOlT._
<br />
<br />Adom
<br />
<br />Richard
<br />
<br />Sokol
<br />
<br />Male
<br />
<br />April 27 I 2000
<br />
<br />e. OATE Of 81ATH ,_.llo. V_
<br />
<br />.. ClTYl\NO "teOfIllTH ,......US~__f1
<br />
<br />50 <Gl! _.....
<br />IV.. '93
<br />
<br />_'''''AIl
<br />... W'~ llAYS
<br />
<br />_, llAV
<br />~ HOuIIS _s
<br />
<br />Deceatler 16, 1906
<br />
<br />Platte Center, Nebraska
<br />? SOClIot. 9fCUlm\' .....-A
<br />
<br />.. .~.-
<br />
<br />"""'-,,..--..-
<br />
<br />eo PI./lCEOf DEATH
<br />HOSI'fT.... KJ-
<br />
<br />OE"~
<br />
<br />DDOA
<br />
<br />2!,!"R 0-......
<br />0--..
<br />DOIIto.,s.-",
<br />
<br />508-44-5749
<br />
<br />
<br />St. Francis Medical Center
<br />
<br />---~_..,
<br />
<br />~
<br />
<br />-..~ .,-'.
<br />
<br />Grand Island
<br />
<br />v.. []I No 0
<br />
<br />Farmer
<br />.e .,,~_ FIRST
<br />
<br />1II0D1.E
<br />
<br />17 MOTHeFi
<br />
<br />Hall
<br />Illl STAEET ANO I;UI.llIEA "';"""4> ~I : .. _ CITY L.....S
<br />2204 w. 10th 68803 I ...1) No 0
<br />o "'Xl'M:D I -1 ...- Of!ll'OUSE "'- ___
<br />DhlOACEO Cerolyn Schaehta
<br />," EOUCATIOI< ,-.""",,_..-_
<br />I e~l~!)-iO'2I ~1''''tt1~-1
<br />I - ~ .
<br />rOOST ...roLE MAIOEf\I~
<br />
<br />.. AfSllENCfi - STATE
<br />
<br />Nebraska
<br />
<br />.0 AACE-le-e-._ _"'"-con_
<br />., 'Sooe<trl Whi te
<br />
<br />Thomas
<br />
<br />Kathryn
<br />
<br />Gonka
<br />
<br />II WolS DecEASED EVfA .. uS _D ,<JA(:~S,
<br />fV-AO'~1 \"..9N"""'....,08IIe5Q1~'
<br />
<br />19b. "FOMMHT
<br />
<br />UAUIG AOllI<l:SS
<br />
<br />Carolyn Sokol
<br />ISTREET O,!!,.. D tiO.. CITY OA TOWN_ STATE. ZIP'
<br />
<br />
<br />68803
<br />
<br />211: UETHOO ~ OI$POSIT1Of't
<br />
<br />~ Burial 0 Removal
<br />
<br />.'0. DATE I." CE...cTERY OACREMATOAY .......,
<br />
<br />May 1, 2000 I Gran<! Island Cemetery
<br />21d CEMETERY OR CRUAATOR:y lOC.\lKlN (.I".... ()I:;j TOWN STAtE
<br />
<br />Apfel-Butler-Geddes 0 c_ 0 Donal,""
<br />- F'-"'EAAI.~AOOlIESS ISTRI'<T0<1 Il-F.D tiO CJTYOATDWNSTATE.Z1P,
<br />
<br />Grand Island, )JE
<br />
<br />1123 West Second, Grand Island I NE. 68801
<br />Z3 _TE CAuSE !ENTER ONlY ONE CAUSE PER LINE FOR ," ,01_ AND ,e,1
<br />PART (
<br />I '" 'Arz.(:)I~r->u.l.""wv' ,lJ-OA A(lRA:4'-(
<br />Il<IETO.ORASACONSEQVEtlCEOF V
<br />IlJI 8 ~ ~,J-) ,.,j :L71f ..Ju.8 Qwz.x.- 1..1- ~-II."..o
<br />DUE TO. 011 AS A CONstOUE'lCE Of'
<br />f fh..<<- 4"- ,..k rrIL
<br />
<br />.....'4I.~m.-a'1Q!jE:#'
<br />
<br />:JA "'V&4 U ('L.
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<br />"'~Ii~ ~ ~ OMII"
<br />
<br />}~j
<br />~ (IIlIIIM.-::~
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<br />OTHERSlGlWICIINTCONOfT.,..S-C<o1doOoo5"""""""'ng.........",......,._ -nARtIlIlFFEIIIAlE INASTHERI'A i 2. ."TOPSy
<br />PAIlT I( -r I P~fG"'NCY IN THE PoSTJI.4ONTHS' .
<br />· D t """-..; j:.4 I 'Ages W,'"" n No 0 i Yo. 0 No
<br />210 .. DATE INJURY IMo. D,,,, V,I ~ HOuR OF INJUR. '2M DOSC"'BE HOW'NJUP,<>CCU_o
<br />'+ f Ih-L !J- -r th ,.Ji.
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<br />" W~~~~OTO~-
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<br />e-:)'~",OA~P"'"
<br />
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<br />~ lOCATION ~tRf:E"t OR ~ f 0 N() (.!h' OR 1~
<br />2.-~lJ If W lOr'" ..1.-). '~/lJ(..
<br />,
<br />l 2'fta O.TE'StQr-.Eo 1Mr.l Od~ ~f I 1* TIIW; OF Of.a.r..-
<br />
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<br />21.T1MEo:.?~_~lj!.lil~.~~ -~" i-~''''"~
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<br />".,::. .. ..,. tN'T'oi& 0IMI'tnr.' ptKe~"/C cluI' 10'" ,:.,.,,: .-a
<br />I ~IS>gO.........T...,..
<br />30. "AS OtIGAN OR TISSUE OC)NAT.,...:J:' CON9IOl:. RED'
<br />o UNK~N 0 YES E ""
<br />31 NAME A/I!O _SS OF CEATlFIEIlIPHV8lCIAN. COROOlERS PHYSIClO.N OA COIJNTV 'T1O<1N<Y, ,'~'" "''^''
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<br />l30b wASC~..Ji!"TGAA""'tc:UI
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<br />
<br />M.D. 716 Alpha St... Grand Island, NE. 68003
<br />
<br />~ _ - ~~ ~""'""MAY -5~-=
<br />
<br />EXHIBIT A
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