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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH''''''';'' ,
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGl ' ':J"N01!fI{'OfZ S~RVICES
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM VITAL ST~~~rfflJC W,ITH
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ' ljiJ .' ~>~~J\l:l= ~r.~:;.~~~:~s
<br />
<br />DATE OF ISSUANCE : J -: ~ . . ~ ','
<br />t '" VII .
<br />
<br />MAY 0 2 2008 :0:: f fBitac~:
<br />LINCOLN, NEBRASKA 200 8 0 5 6 ;) 7 : :A~I6TA ~/S1jRli,il:.
<br />~itff'H. A"fD,HUMAN5,ER.V/~S:
<br />. ,,?<~~~~p.:~ ::~'.:-":'~ ':~'.:::";-"~
<br />
<br />, ' "'. ,,; ~".'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN'SERVICES f'1t.lANCl('{NJi'sUPP6' '8' 2 4 6 4 4
<br />CERTIFICATE OF DEATH . '.' . _.'.' ~,' .
<br />
<br />1. DECEDENT'S.NAME (First,
<br />James
<br />
<br />Middle, Last,
<br />Robert Czaplewski
<br />
<br />Sultlx)
<br />
<br />2. SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo.. Day, Yr.)
<br />April. 2l., 2008
<br />
<br />
<br />a. DATE OF BIRTH (MO., Day, Yr.)
<br />
<br />So. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY Of BIRTH
<br />
<br />SA. AGE.LAlt BirlhdAY Sb. UNDER 1 YEAR
<br />(Yrl.) MOS. DAYS
<br />74
<br />
<br />June 19, 1933
<br />
<br />Loup City, Nebraska
<br />
<br />88. PLACE OF DEATH
<br />~: . OlnpAUlnt
<br />
<br />QII;IEB: al Nurling Home/LTC 0 HooplOl FAcility
<br />
<br />1. SOCIAL SECURITY NUMBER
<br />505-36-9143
<br />
<br />o D.ced.nt's Hom.
<br />
<br />ab. FACILlTY.NAME (If nol InsUMlon, glv. slr..t and numb.r)
<br />
<br />Cl ER/Outpatl.nt
<br />
<br />Tiffany Square Care Center
<br />
<br />o Other (Specify)
<br />
<br />ad. COUNTY OF DEATH
<br />Hall
<br />
<br />00)\
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />Grand Island, 68803
<br />
<br />
<br />9t. ZIP CODE
<br />68801
<br />
<br />9g.INSIDE CITY LIMITS
<br />al YES 0 NO
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />9d. STREET AND NUMBER
<br />328 Holcomb st
<br />
<br />- .
<br />lOA, MARITAL STATUS AT TIME OF DEATH !XMarri.d 0 Never Married lOb. NAME OF SPOUSE (First, Middl., Last. Sutfix)It wlta, give maiden name.
<br />
<br />o Married, but ..parated 0 Wldow.d ODlvoroed 0 Unknown
<br />
<br />Arvada Nida
<br />
<br />t 1. FATHER'S.NAME (First,
<br />Bernard
<br />
<br />Middle,
<br />L.
<br />
<br />LAlt, Sulllx)
<br />Czaplewski
<br />
<br />12. MOTHER'S'NAME (Firsl,
<br />Angeline
<br />
<br />Mlddl.,
<br />
<br />Malden SurnAme)
<br />Mendyk
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c. DATE (Me.. Day, Yr.)
<br />Apr 25, 2008
<br />
<br />CITY (TOWN
<br />
<br />STATE
<br />
<br />Grand Island
<br />
<br />NE
<br />
<br />PART I. Enter the ~~..dlseas.s, Injurl.s, or compllcatlons..lhat dlr.clly cau..d tho d.ath. DO NOT emarts,mln.1 "".nls such as cardisc arresl,
<br />reepiralory erresl, or vAnlriculer fibrlllellon without Showing the etlclogy, 00 NOT ABBREVIATE. Enter only one cause on a line. Add addillonal line. If nec,,"ory.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />on.et to d.alh
<br />
<br />IMMEDIATE CAUSE (Final
<br />1lI.....or condl1lon rIIulllng
<br />In doeth)
<br />
<br />(al C'" CLr
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />tA.,.J-.....o,)w.....
<br />
<br />
<br />ons.t to death
<br />
<br />~t
<br />
<br />(0) lk~~- P;'~
<br />
<br />DUE TO, OR AS A ONSEQUENCE OF: )
<br />
<br />C~
<br />
<br />Sequentially lIet condition., If
<br />any, leocllng 10 the OIu..llotad
<br />on IIn...
<br />Enterthl UNDERLYING CAUSE
<br />(di..... or Inlury th.t InitiAled
<br />thieve,"" ....ulllng In dotth)
<br />LJ6I'
<br />
<br />on.et to d.ath
<br />
<br />(c)
<br />. DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to de.th
<br />
<br />(<I)
<br />
<br />'9. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES IX NO
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditiuns conlrlbuting to In. dealh but not re.ulting In the underlying cause given In PART I.
<br />
<br />- S i~'tr ~ t<r~l..J v....l.t
<br />
<br />20. IF FEMALE:
<br />o Not pr.gnant wllhin put y.ar
<br />o pr.gnant at tlm. of death
<br />o Not pregnAnt, bul pregnant within 42 day. of dellh
<br />o Not pregnant, bUI pregnan143 days to 1 year belore d.eth
<br />Cl Unknown if pregnant within the put year
<br />
<br />21 b.IFTRANSPORTATION INJURY
<br />o Driver/OperAtor
<br />
<br />o PAssenger
<br />
<br />o Ped.slrian
<br />
<br />o Olher (Specify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES
<br />
<br />Cl Accld.mO P.ndlng Inve.tlg.llon
<br />o Suicide 0 Could not be det.rmlned
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />22e. DATE OF INJURY (Mo., D.y, Yr.)
<br />
<br />220. TIME OF INJURY 22c. PLACE OF INJURY.AI ham., farm, street, fsotory, offic. building, construcllon .itA, Ilc. (Sp.cify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />
<br />CITYITOWN
<br />
<br />o YES 0 NO
<br />
<br />STArE
<br />
<br />ZIP CODE
<br />
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />m
<br />
<br />Z>
<br />E~~
<br />liij~
<br />I."~z
<br />"ffi" 0
<br />..,zo
<br />~~~
<br />
<br />24s. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAO (Mo., Oay, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis 01 examinAtion and/or Inv.stigatlon, in my opinion dealh occurred et
<br />Ih. time, date and place and due to Ihe cau.e(s)llaled. (SlgnAtur. and Title)"
<br />
<br />25. DID TOBACCO USE CONTRIBUTETOTHE OEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />o YES ~. NO 0 PROBABLY i~NKNOWN 0 YES :a NO
<br />21. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Chad w. Vieth 2l.16 W. l!'aidl.ey Ave., Grand :tel.and, NE 68803
<br />
<br />25b. WAS CONSENT GRANT EO?
<br />
<br />Not Applicable If 2aA il NO 0 yeS III NO
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAY 1 2008
<br />
<br />J/
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