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<br />STATE OF NEBRASKA ~
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND UMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECO D ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlST~ts..",.~_N, WHICH IS
<br />
<br />:::;::~::::::;TORY FOR VITAL RECORDS_. _ y.. =~ _.~~~::,~,~~
<br />'Ti?"'~EY S. ~'hPER
<br />SEP 1 S 2007 20070810 5 g4'SSIS'fANT-STATE;oREqi:~i~AR
<br />LINCOLN, NEBRASKA ri.TffiNlJHiJMiW:.~7!fES
<br />
<br />~ ~:;;';'...-.":"'" ~
<br />- _ ~~~.,~'~_;~=:-J.-.2 ~~~c
<br />
<br />.S. TATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SE.R. VIC~':;~~ORT C 'J; 7 A.l"\7.'
<br />.~. __n CERTIFICATE OF DEAT!:t -",~ . o.~
<br />(First, Middl., Last, Suffix) 2. SEX Ie 3. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />John
<br />
<br />Valasek
<br />
<br />July 2, 2006
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cedar Rapids, Nebraska
<br />
<br />5a. AGE-Last Birthday 5b. UNDER I YEAR
<br />(Yrs.) MOS. DAYS
<br />80
<br />
<br />5c. UNDER I DAY
<br />HOURS MINS.
<br />
<br />June 17, 1926
<br />
<br />6a. PLACE OF DEATH
<br />1:!l2S1'lIAI.:
<br />
<br />~ Inpatient
<br />
<br />illI:JEB: D Nursing Home/LTC D Hospice "acility
<br />
<br />U n.-.+ ;n"tit~HI.o4,. ~~e-g.,t---a-R-Q. nlJffib~--.- ..__ __.~_ _ .___
<br />
<br />d ER/OutPa-ti~nt
<br />
<br />---- -dD.~.d;~t's H~";e
<br />
<br />St. Francis Medical Center
<br />
<br />6c. CITY OR TOWN OF DEATH (Includ. Zip Code)
<br />
<br />D [X)i\ D Other (Specify)
<br />6d. COUNTY OF DEATH
<br />
<br />Grand Island
<br />9a. RESIDENCE-STATE
<br />
<br />Hall
<br />
<br />~11
<br />
<br />
<br />68803
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />91. ZIP CODE
<br />
<br />gg. INSIDE CITY LIMITS
<br />~ YES D NO
<br />
<br />606 N. Ruby Street
<br />lOa. MARITAL STATUS ATTIME OF DEATH IllI Marrl.d D N.ver Marrl.d
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Suflix) If wif., give maiden nam..
<br />
<br />D Divorc.d D Unknown
<br />
<br />Mary Louise Vlllll!'H:ll Knapp
<br />
<br />Middl.,
<br />
<br />Laet, Suffix)
<br />Valasek
<br />
<br />12. MOTHER'S-NAME (First,
<br />Anna
<br />
<br />Middl.,
<br />
<br />Maiden Surname)
<br />Kowalski
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />
<br />__:Michael
<br />
<br />John
<br />
<br />13. EVER IN U.S. ARMED FORCES? Giv. dalee of s.rvic. if Y.s. 14a.INFORMANT-NAME
<br />(Yes, no, Drunk.) Yes 1.2_5)-1953 David Valasek
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />J-;-Sb. LICENSE NO
<br />
<br />
<br />CITY /TOWN
<br />
<br />I Be. DATE (Mo" Day, Yr.)
<br />July 3, 2006
<br />
<br />STATE
<br />
<br />lBa. EMBALMER.SIGNATURE
<br />Not Embalmed
<br />
<br />DBurial
<br />
<br />D Donation
<br />
<br />crer.mation D Entombment
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />D Removal D Oth.r (Spacify)
<br />
<br />Westlawn Memorial Park Crematory, Grand Island, NEbraska
<br />
<br />.. ~ ~
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, City orTown, State)
<br />Livin ston-Sondermann Funeral Home, 601 N. Webb Rd., Grand Island
<br />
<br />
<br />P RT I. Enter the ~~..dlseases, injuries, or complicationsnthet dlrectiy caused the death. DO NOT .nter terminal ev.nts such as cardiac arrast,
<br />r.sp"atory arrast, or v.ntrlcular lIbriliatlon withouf showing the .tiology. DO NOT ABBREVIATE. Entar only on. cause on a tine. Add additional lines If necassary.
<br />IMMEDIATE CAUSE:
<br />
<br />I
<br />; ~se1 to death
<br />
<br />: 1 K'\.~r--. \.
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condition ,""ufllng
<br />in death)
<br />
<br />(a)
<br />
<br />~ \:--s, ~
<br />
<br />~&..~~~,
<br />
<br />f-~~~.~L.;
<br />
<br />onset to death
<br />
<br />
<br />infection)
<br />
<br />Sequ.nti.lly Ii.t conditions, if (b)
<br />any, feadlnglOthec.u..liated DUE TO, OR AS A C
<br />on line a.
<br />EntertltoUNDERlYING CAUSE
<br />(dl..... or InjuIY lhat inili.t.d (c)
<br />thee",mte""'ulllngIn d.ath) DUE TO, OR AS A CONSEOUENCE OF:
<br />LASr
<br />
<br />onset to death
<br />
<br />ons.t to death
<br />
<br />(d)
<br />
<br />.~ -,
<br />lB. PART II. OTHER SiGNIFICANT CONDITIONS-Conditions contributing to the d.ath but not resulting in the underlying c.us. givan In PART I.
<br />
<br />
<br />__.~~"J~\ \>\Xr-- k '-~ R-D-_
<br />
<br />~ ~ANt:!$R OF DEATH
<br />I::o.,.r.tural D Homicide
<br />
<br />. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES \.9._"/>I.'h
<br />
<br />ZJ€ WAS AN AUTOPSY PERFORMED?
<br />
<br />D YES ~
<br />
<br />c~
<br />
<br />
<br />\--.
<br />~r
<br />
<br />20. IF FEMALE:
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />CJ Driver/Operator
<br />
<br />D paasanger
<br />
<br />D P.d.strlan
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES D NO
<br />
<br />D Not pregnant within past y.ar
<br />D pr.gnant allim. of d.ath
<br />D Not pregnant, but pregnant within 42 d.ys 01 d.alh
<br />D Not pregnant, but pregnant 43 days to I year before d.ath
<br />o Unknown if pregnant within the past year
<br />
<br />D AccidentD Pending Inv.ellgation
<br />D Suicide D Couid not b. delermlned
<br />
<br />D Oth.r (Sp.cily)
<br />
<br />22d.INJURY AT WORK?
<br />
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY-At hom., farm, Slreet, factory, offic. building, conSlruction sif., etc. (Specify)
<br />
<br />m
<br />
<br />DYES D NO
<br />
<br />221. LOCATION OF iNJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STi\fE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />~~1ii
<br />llCii~
<br />ll>~
<br />l~~~
<br />
<br />,8z;i!
<br />~~~
<br />
<br />24e. On the basis of Elxamination and/or Investigation, in my opInIon death occurred at
<br />the tim., date and place and due to the cause(e) stated. (Signatur. and Tltie) ...
<br />
<br />m
<br />
<br />23c. TiME OF DEATH
<br />3: 32 pm
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />21WAS CONSENT GRANTED? ~
<br />Not Applicable it 2.sa is NO DYES 't:rNo
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />'JUL 5 2006
<br />
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