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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE <br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY <br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DVAI E1T OF. HEALTH <br />BUREAU OF VITAL STATISTICS, WHICH IS THE L L.�fDEPOSITAY FOR <br />VITAL RECORDS. <br />DATE OF ISSUANCE <br />87-104980 <br />AUG 19 W STAN, Eq :S. COOPERg, DIRECTOR <br />LINCOLN, NEBRASKA // Q BURE a/�AU'4F'/VI� STATISTICS <br />Zo�( <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH T <br />Bureau of Vital Statistim F- 7 5 07124 �I <br />CERTIFICATE OF DEATH, j/- c%� <br />D1CtA710 —NAMt ••• +r "+a• r••r x <br />DAtt W D[AM , «o «rw, ..., .... r <br />LEO GEORGE VA%ASEK ! MAI•E <br />dime 26 1975 <br />1/10E war, "•e•o. •.w•rc.« na•a• «, <br />AGE —tur <br />rpw• r <br />ww• r DATE OF 1101M. .rorpw. N . <br />COIM/TT d DEATH <br />p0, .... <br />free <br />x.wr'•9. r.f.•7r <br />rrorw• ra nN12 -22 <br />—"7 <br />Hall <br />• <br />h <br />M <br />to • <br />11 <br />l • <br />r <br />w I phwNo, •r «r•N r <br />"OSHA OA O �aIr <br />trtGrand <br />Island ,~Ye <br />s•�"N <br />Veterans Admin—iNstraptiM o n sapw i l <br />STAR OF 90M.. aror w ..... «..e <br />COMM Or WHAT Co111R1v <br />M�,,pM�EwD�. N�pVrvMp <br />SU1YIVNG SPOUSE r p �•M, am .•rw« .r..r r <br />E Nebraska <br />E USA <br />�MAEMMD. <br />,� DIBI'1'1Ca °'xfcnr <br />„ Grace Crooks Valasek <br />socia SECIMITT Numm <br />UVJM OCCUPATION ions .pre W .ro•• •o"f s•xrra r W <br />EINO OE MISNESS d INMMY <br />507 -16 -6428 <br />°G"tarpenie "r yls <br />Construction <br />„ <br />, <br />M <br />10101NQ —STAR <br />cook" <br />CAT'. TOW". 01 LOCATION <br />rw•re1 [m tp M <br />SMKI AND NUMM <br />Nebraska <br />,+ Hall <br />Grand Island'a�Yes <br />�' <br />1324 W 4th St <br />.«..Rw —nwwr arAr <br />Me. (dec.) Michael <br />WWAS DKINU a •n1 M• U.S. AWAN <br />Ph'A l ft-1 I If -* <br />Ik IM Ih <br />preRl r•x Mpl}Mf— MAfDtN NAME rwtr crap! u•r <br />Valasek „• (dec.) Anna Kowalski <br />"01MAW— NAME— Bf1AT#0N7NN— MA<MI(' Aww$s sntx W •.a.•. pa, C- M 10—, x.". W. <br />' , Mrs. Grace Valasek,wife,1324 W.4th,Grand Island, NE <br />AM 1. D1ATN WAS CAUSED K <br />irMrEr ON/T ONE CAUft fEE lM NJE fel. RI. AND kll <br />MMN" O"NI .are NA"r <br />M <br />ai Carcinoma of the stomach <br />with metastases <br />Unmown <br />CMN"Ma, " •w <br />j <br />C. a•.E 1rN q <br />I1•I <br />r.twEMAI• GYN a•r, <br />,r ANwa TM <br />7I eM .O. O• N . COr.MOY•KI d <br />urefs <br />area [•YN .. <br />01 <br />010 a OTNM YONVKAM COMM ON& CO6411"M • CONIEMITwm To BEAT" WT rqt •N m <br />•AM a • fWME, WAt "Mal A <br />AUTOPS/ <br />M TES ww "aNrwot car <br />N la1M OIYEII M PM MI <br />.aIOMYfC1 w IaN ►AET 7 wpwiNef <br />. m a .car <br />xDEEN r« NNMx«r.N GYM <br />"M ❑ "D ❑ <br />w y @3 <br />I: NNp yes <br />. . I/O•MCOE. <br />CN INAW <br />Now MANY occunto I«"• ...rra•1 r" rwrv•r r« a.•r r a.Nr rr, par .. r <br />�IMrx•[w.r <br />7M <br />fM M <br />no <br />oe0 w <br />roc ' a•r. /Hoer. r.n0•.. <br />tOCATION xwa w . a e "a . a" <br />ItwErw m r <br />,ya.. nc r <br />7M <br />Mt <br />i1111161CAMPON— <br />"" "w 9, 1975 To dune <br />19 <br />o- <br />J% 1975 <br />1 M <br />. <br />" .rte <br />oCCYYp <br />"°4:09a •r "" •f»4[f•, a o- .. r rNw x <br />"Fehr. <br />M N <br />!N <br />th <br />M. to rrrf Oa <br />EBIBI aiBllrrp Pr NO « <br />W M W 19 "rE ~AGMf"I x.M�w •^ •+• ws/v�. v. w..n rOr.rp Yt "N rqY. - -•• •• —•_ <br />r11/E ON rwrn • , ,E`it I-Lt n Tj a 30 w1975 1 <br />i C. D. DANIEIISON• M.D. :, <br />}h <br />�3yr"' <br />4 lYGUl aV. ;Ni_ <br />, • EEOILNM <br />71"t- <br />-i <br />