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- s:s-�. d.r 1, .,�, a..• rs �""..
<br />Rp. Of peEds
<br />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 DEPARTME�iT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY F 102220
<br />VITAL RECORDS. L
<br />DATE OF ISSUANCE
<br />�<i'T "
<br />SEP 2 0 IMS STANLEY S. COOPER; .DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU OF.- VITAL- STATISTICS
<br />STATE Of NE/RAfQ- DEPARTMENT OF HEALTH
<br />BUREAU Of VITAL STATISTICS
<br />CERTIFICATE OF DEATH 1 __
<br />DICID9PIT-NAME MIDOLI ,DATE OF DEATH (M.. D.,. 1")
<br />1.
<br />Dennis Joseph 2Lzczey !x male 1 Au ust 29; 1985
<br />RACE_(. �.• ib, Ole. R. A— i— OM6fNIOE3CENTl ..R.,IMIi.w, :AN.i..w. .GE -lw ■inANr UNDER)YEARYEAR UHOE.I OAT OAIE Of MIRTH (M... Dar. T,.)
<br />tj(� /) G ,'MI,.)ES�.,,�) )69 S. ' DAYS iaOVRS • MINS. x Jul 4 1916
<br />1. " P 1 I NAME Or SPOUSE (U.ib.
<br />1 A A • Of OIRTH (" A., iw U.S.A.. CITIZEN OF WHAT COUNTM'ASARRIED, NEVER MARRED, O"•
<br />nel.. .e,,,N,Y) WIDOWED. DIVORCEO(Sp.nfr)
<br />M.T v N ra ka r. U.S.A. to married Evelyn Stobbe
<br />SOCIALSECUMIY NUMOER USUMOCCU /ATION(Gi.. fiwd.f ..rf duw ..nwpwl.p KIND Of MUSINESS Ot IMOU�O COUNTY Of DEATH
<br />./..,AiwIT "f., nNr.I)
<br />17
<br />-Q2-3936 ue.Sal s to Institution != 7 IauCand Tobacco rb. Hall
<br />INSIDE CI1T lwITS HOSeTA/OR OTHER INSTITUTION -Hew,. (1l n.l ,n .nb.r. "NOS) OE r.51
<br />CITY, TOWN OR LOCATION OE DEATH '"SIC! Y., nriwb.,) ■,w. I,«n•wl rsv.,•,,1
<br />I r d Island I4. es Iw � Medical Center LIA. inpatient
<br />CITY. TOWN OR CCATIOM STREET AND MUMMER INSIDE CITY llMlt$
<br />RESIDENCE -STATE COUNT!
<br />13.. Nebraska Isb. Hall Is<.Grand Bland lisd1019 East Nebraska Ave 'IS.yes
<br />A -M fit MAIDEN NAME FIRST MIDOIE USA
<br />I. c Michael
<br />Placzek IT (Dec) Mary Laska
<br />WAS DECEASED EvEE IN U.S. AWED FORK INFORMANT -M..1f -- RELATIONSHIP -- MAILING ADDRESS Isnf(r o, ■ r D NO. an W Tow6.8801u�1
<br />CT.,, ». w rw31 IM NN. ■"■ — ^ ^d M'^• .' v, I
<br />u.Yes III 8 -17 -42 12 -26 -45 �IgEvelyn =Laczek, wife 1019 E Nebraska,Grand Islam ,NE
<br />OUMAL, C,. —S.n. RN-1 A CEMETERT OR CEKVATo" - NAME I LOCATION CITY D• TOWN STATE
<br />xo..Burial 2D6. .3 1 x «.West as Llwnri al Park i X)d Ol-
<br />- SIGNATURE A EKENSE FUNERAL NOME -•AME AND ADC!ESS ISi■en OR E r D NO. Cl" ON row.. SEAT , x111
<br />d I 12;AvingsUn- Sondernnnn,505 W. Koenig,Grand Island, lie.
<br />21, EM DATE SIGNED (MO. D.P. Y, ) HOUR OF DEATH
<br />DATE Of DEATH (AE.., Der, Y,.)
<br />— — -
<br />2s■. ALL st 29 1985 ;�o x'° 1i M
<br />MOUEOFOEATH PRONOUN[ ED DEAD PRONOUNCED DEAD (NOrrl
<br />A RED(".., D.P. Y,.) -'�:
<br />�i 23b. 1985 13c. 11:55
<br />L •■" I■dNR R . wA.arrN .1 1I, ,. /� �-� _- y t • ,G v rIeSi. , dw.er,. r w « .d N P I «l;d.N.N ► d
<br />r• N M. wtra1Hd
<br />4— h ►.,1 .1 .i «I« owdf.r w16,6w ,. 1 ,ir.
<br />IxA. T. l■. bw w
<br />IsrN i ► R NCORONERS PHYSICIAN OR C:UMIY ATTORNEY) (Trp. ,I
<br />ADOlE35
<br />s.,w.w d..M .,w•,N aM ,
<br />I,inl)
<br />ti is M. Pinto M.D. VA Medical Center 12201__N_.__Broadwei.lfGrand Island, NE 68801 __
<br />STRAE D TE RE YED OY REGISTRAR (M, .. D,y' Y, I/
<br />V IENTERONLY ONE CAUSE IER LINE FOI 11. 111). AND (,)7 InNrva s,-..• «.«.wd d «M
<br />PART 1 Day
<br />Acute respiratory failure - --- - - - - --
<br />OUIT 10. OR AS A CONSLt7UENCE OP:
<br />7 Days
<br />,., Pneumonia - -- - - - - - -- -- .NMIV. » - -- -- -
<br />DUE TO, OE AS A CONSEQUENCE Of:
<br />____ -_.
<br />TART - C.ndd:.w, <«,^br,in. ti IMl• ti, .N • �'.� NLGNAHC 1f. 1INT ,ASr
<br />.0.7. 15NO0r IN s. N.:� E■AM N! E WICO■ON! n•L dCAI
<br />it fp.l, ♦„ • Ns
<br />R
<br />Severe COPD • ASHD '•• H. xM
<br />KCIMM. SLRCIM. N'OMICIOT. IL.DET . DwrE Or I.ruEY IAI•.. D^r. • I our <r Wuir - -� j otunsi NGwiruu■r tiCt u■■to
<br />r
<br />OR M,IOMD INYMSDRAITON. (Sp•,./,/
<br />SDd_. _. .. ... ....... ..__-- -'--'..__.._--__.-_ ----.V
<br />M111R'I Af MOR nACE p N11VRT- Ar A•,» l.,^. .wr. 1•n.r) IOC AI,ON ST ■L!1 U. E 1 D N. CITY O■ IOwN SIAM
<br />7
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