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BIMIAI, CREMATION, REMOVAL C TERY W CREMATORY —NAME LOCATION CI. 01 10wx N•11 -
<br />$urial Westlawn Memorial 74t Grand Island Nebraska
<br />Fh. 2H
<br />DATE I MOMM, p•T, nn1 FUNERAL HOME —NAME AND ADDRESS N.111 O. I! 0 .0. 4111 01 tOwx, NMI. HI I d Nebr. 68801
<br />FM i7 is. bMf Klj[Ir90 4 LOCAL AEGIS I RAE
<br />R -3 ATURE LIKEN NFo L,y /� REGISTRAR— LGNUUEE /J © /![J, /y�/�/.�I•jG( CIl / /9 / /�/
<br />IN
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT OF HEALTH. BUREAU OF VITAL STATISTICS, WHICH
<br />IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />A A .
<br />DIRECTOR OF VITAL STATISTICS-AND-ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued September 16, 1976
<br />LOT THREE (3), BLOCK TWO (2), IN PARK PLACE ADDITION TO THE CITY OF GRAND ISLAND, HALL
<br />COUNTY, NEBRASKA.
<br />STATE (IF NEBRASKA - DEPARTMENT OF HEALTH
<br />BYr!'R1N Of Vital ti(AIE.IIDB ���
<br />CERTIFICATE OF DEATH. C•b .�� 1 f)6805
<br />rl.ou I.1• EEK DATE D A H +row x, e•r, run
<br />DEC ASEO —NAME lu„
<br />STEPHEN L CARKOSKI , Male , Sept. 3, 1976
<br />r
<br />RACE WWII. MO q, •w.KAX lxel• AGE- 11 _ et_ T... u«en 1 o..rw D� �F 01 BIRTN IrOxrx. o•r, COUNTY OF DEATH
<br />" V+Of ,
<br />.1.1 «.. L.fI D••I xOUIS Dee. 12, 1906 ,I Hall
<br />I White „ tl 1 n
<br />wm HOSPITAL OR OTHER MSTITUt10N —NaMf »01 1» «Inn. oNI SINN AnD xuwn 1
<br />CrtY, TOWN, OR LOCATION p[w \H
<br />vlan .Tf a no
<br />Grand Island Yea „ St. Francie_Hoapital
<br />,,
<br />STATE CN BIRTH. n xol Ix u s • x•w CITIZEN Of WHAT COUNTRY MARRIED, NEVER MARRIED, EUDvIv-_ SIOUSF , N Wnl, Dlr! r•INx x•w ��
<br />WIOOWE DIVORCED .NNX•I Marie Krum
<br />Married
<br />D Nebraska E U.S.A. n _�_' -- -. .. -_,_ -. _..
<br />SOCIAL SECUINfY NUMBER USUAL OCICUPn'ION' .'4, nlwo of Ww. ROx1 ou.Iwc ro11 0� KIND Of BUSINESS OR INDUSTRY
<br />506 -03 -8755 It. Metal Smith ZED Metal wor_king_______
<br />IF rxf101 U. Llrnf STREET AND NUMBER
<br />RESIDENCE —STATE COUNTY CITY, TOWN, OR LOCATION I s,, rn o. x01
<br />Yea 511 W. 15th
<br />Hall Grand Island I.D
<br />,,,Nebraska
<br />.M+ NAME HHA rIDDN uli
<br />MTHfS —NAM! lln, wee11 IMOYNIP
<br />Sophia -- Jablonski
<br />John -- Carkoski „D
<br />O HI WAS DECEASED EVER IN U.S. ARMED FORCEST INFORMANT - NAME - RfUTIONSNI►- MAILING ADDRESS nnln o.. T o xo , cn• o. IDg1881Q11 mr
<br />5..
<br />Rn. fru.xl III I 1.
<br />08 u. Mrs. Marid Carkoaki- wife -511 W. 15th Grand Island Ner'r.
<br />ART I DEATH WAS CAUSED NY BEN /fR ONLY ONE CAUSE IfR TINE FOR (O , 20/. •nU 1.21 n•1ex Oxfn —_
<br />-N
<br />„ xmeon CALL. - S
<br />= px011rOw3, �_. --
<br />cx o•rl I'll 10 o
<br />rruunl c• ufa 1e1, jl ow +o, w •s • co «slowxcl or
<br />su-
<br />c w ,•u
<br />IR7 AUTOPSY If YES WI.1 Irx Dlx4f C."
<br />PARE H WHEN SIGNHKANT COHOIf10NS COHDIT10N5 CONfI1RUTING TO O,A7N RUT Hof AlLAT10 "IFIAL1. WAS T-111
<br />M THE IASI ] MONfXST I r15 O. •�Tr O. 01.1 x" DIN....... c•uf1
<br />TO CAL, I GnIH IN IAA1 y.l /•.E/
<br />T11U NO [1 IM I*
<br />HO IN7URY OCCURRED Iw1e. »•run of I »1u.• I» IM1 I o. IM1 II, nlr +I I
<br />ACCIDENT, SUICIDE. HOMICIDE, A IN I r0«1 ». o •. MOW
<br />OR UNDETERMINED 1 MC1rT I
<br />7� T„ 2% A, tY
<br />INA/fT AT WORK PEACE Of MINIRTAY. ow. rnr, In!!I, ..cTO.T, 10[A110N I fnlN o1 . 1 o Ho . on
<br />IfnC1n n1 O. x01 OINCI NOG IK IfIKI.I
<br />�'
<br />D•T „1•I •MD 4fi yW nW /n1. •Llrl O» I D D »01 rn M! Of AtN OCCUARI0 •• 1 «!'"CI, O» 1w
<br />`•r
<br />roww If D!•Mw ,x0 A E� D•n 10 ME N11
<br />CERTNICATION— rernx p•• •1•. rD »w • .. .ODr u,
<br />•MwIEDDI, Dw
<br />'..
<br />••»O.
<br />PHYSICIAN: IO • Iq� b 711e DID �yl_
<br />tw '1 , 1� �1 �� —, 1 O 7« M O MI C•uf «H 11•nD
<br />'..
<br />.1x010 _ IO 71, Ilr
<br />�•
<br />�— —
<br />TI. OIC!•MO LIZ l xe IICIOtI•I vt ..OwOD »CID De•D
<br />1
<br />C[RTMIULTpN- MEDKAL EIAAUNER OR CORONER o» 1x1 uus or Iw xow o. Durx ro »I« D.. n•.
<br />`
<br />IAUw•Igx of nn wos •xo /o11w r »rlslw•1Io.., ,« +• wwlo »,
<br />E'
<br />aur« occu.nD oN wrf o•n .xo ow 10 1x1 nwusl suno 71D
<br />77. — - =14N1 m Inn OAiE 51�7Nf�' p o•1. Te•I I`.<
<br />CffililER Inn ON nw,l
<br />-NAME
<br />L.E. Imes M.D. 771 7H
<br />BIMIAI, CREMATION, REMOVAL C TERY W CREMATORY —NAME LOCATION CI. 01 10wx N•11 -
<br />$urial Westlawn Memorial 74t Grand Island Nebraska
<br />Fh. 2H
<br />DATE I MOMM, p•T, nn1 FUNERAL HOME —NAME AND ADDRESS N.111 O. I! 0 .0. 4111 01 tOwx, NMI. HI I d Nebr. 68801
<br />FM i7 is. bMf Klj[Ir90 4 LOCAL AEGIS I RAE
<br />R -3 ATURE LIKEN NFo L,y /� REGISTRAR— LGNUUEE /J © /![J, /y�/�/.�I•jG( CIl / /9 / /�/
<br />IN
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT OF HEALTH. BUREAU OF VITAL STATISTICS, WHICH
<br />IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />A A .
<br />DIRECTOR OF VITAL STATISTICS-AND-ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued September 16, 1976
<br />LOT THREE (3), BLOCK TWO (2), IN PARK PLACE ADDITION TO THE CITY OF GRAND ISLAND, HALL
<br />COUNTY, NEBRASKA.
<br />
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