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85-- 003638
<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 DEPART
<br />?ENT OF,, HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEP©SJi •�0
<br />VITAL RECORDS." �.
<br />DATE OF ISSUANCE
<br />- JUL 2 2' STANLEY §: COOPER, DIRWTOR
<br />LINCOLN, NEBRASKA BUREAU OF V,T ; 3TgISTICS
<br />STATE OF NEBRASKA - DEPARTMENT Of NEALTN
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />Andrew - - --
<br />E -a.f., w.K• lrl•[F, AwNi•ww p,D Siuda Jr. Male s
<br />, July 11, 1985
<br />,� f1TJ(SI.1 ! /�� T�N�MESCENTI•, f „llw,;w„ ,y,iM A6E -� RI.rA/•T UNDER 1 TGf UNDeR DAT
<br />1
<br />�/ M.�w•, NT.1(S'.ci /YI (I +. J DATE p M.
<br />MAY” (A, 0". Yr.,
<br />f. White S. American b �/ Mof. DAYS NOUfs • A INS.
<br />A fNM( wN iw Y.S.A., CIUEENp WNAi CONNi A1ARM D, NfVef MARRIED, r. Aug. 3U, 1910
<br />4.
<br />tom. tibory, Nebraska U.S.A, W1DOW E (sr«/►r NAMepsra'ur ""a'''"'»'r' """•,
<br />SOCLAL ilCLrMiY PrLIMREf USUAIOCCUP Arlon (Gi- &,.N.f.".•w•._,,,,.,,, ap,/DOf �N upINWS, Agnes Ciemnoczolowski
<br />506 -28 -9303 OF."* fil ' �,
<br />,s., �ect�onan ,s� Burlington R.R. �y Hall
<br />TOW"" d IslpOEATN INSIpE[IT'lLM1iS NOSMTALOROTNl RINSTITUTION- Nww•Of••1i.•irA.., MIIOY W_S_ rr 0R0A,
<br />I Grand Island „rN./I�NNIV., fi.w «.+.., a,...,,,,vt�, f..lyw••. rt•�•„
<br />es r,�. �'w1Prancis Medical Center la Inpatient
<br />�SIDENC! -STAR COUNTY
<br />CITY, TOWN OR LOCATION
<br />- T. _Nebraska ,�. Hall �� snefrANONUMftR
<br />Grand Island I -sp-My rNO
<br />- ,H. 1318 W. John rsP.•x'lr�'sf'N•r
<br />_ N -MAI N N , I S•. _
<br />, Andrew --- Siuda Sr. Cecilia
<br />WAS DECEASED EYER D4 Y.S. ARMED FOfCESY --- GraCZyk
<br />IY•�1O�!"N M.�. F + +..r •....M.....•1 IN�Nr- NAME- RELATIONSNI►- MAKING ADDRESS
<br />1W ISrNfT q f.1 D. NO., Un pf 1pWw, sfAr,, tlry
<br />'a „Agnes Siuda- Wife -1318 W. John -Grand Island, NE. 68801
<br />A MAL `ft-w-- • ~ter CEMETERY OR CRfMATORT- NAME
<br />x.. Burial
<br />July 15, 1985 LOCATION CITYORTOWN STATE
<br />3016. m. Westlawn Memorial Park
<br />LICENSE 'l� /UNERAINOMf_N Md. Grand Island, NE.
<br />.3 AME AND wODfFSS 4511111 w It, o. No_ Carr of rowN, SIATJ. Eal
<br />N OF LNATN ( .�
<br />a� „Apfel- Butler- Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />^ i A N AN. p•Y. Yr.1 NODE OE DEATH
<br />' • W.. 7r. A 11 rlw. rf►.
<br />�_ ,� • ►RON D 11[AD
<br />O.Y. . Y'. , PRONOUNCED DEAD(N•.•, M
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<br />L 'C t NT IAN 2N. /F,wr.r �./ 1a•!
<br />CI0 C TY A Tl f rry•
<br />G. Hrnicek M 729 N. Cuater Grand Island, NE. 68801
<br />R!`YIMMMi+f`/'C�AY rff ONI► ONE CAUSE .ef LINE W. (u. AND v) T 1 S —
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