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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH A':'R. fdJJ/JA/tIi.p,ER VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIN4/"R~C,gFfQPl',FIL~,WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAIJ$~~~~.f;p'W.WI;J)'t;'~/S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,-:-' ~ ,,'"i, p..} 910' ,~~ t1:;: Y r'J
<br />. -.. fL.. ~W:? ~,
<br />DATE OF ISSUANCE ,: ~.; :'. ~./ "'. "', I;;
<br />JUN 1 2 2008 20...0...8. .0... 9. 071. i" ;= : TA{4E-'f'$~" ..QOP:~R -<
<br />':;lSj/~TA SI!JTfit! 0STRk~ ~:.
<br />LINCOLN, NEBRASKA I1EAJ:;f1;l ANPHf!M~t{;E1jVlt~ ,/~
<br />l' ,JI). -t "I I ,:,.,.,','1'\~\'~ ,: I" :''''''.Ii! ~
<br />,I D'. 11! (" .. e. .,,'
<br />l f('. ~"n ~ e\,,' -Ie .-'
<br />STATE OF NE8RASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEf'At-I~jP .:: .;). 'r:: <:1:i"\'::,,1)'
<br />__ _ CERTIFICATE OF DEATH '" J " . / ,v..:{". Q"l er...
<br />
<br />'. DECEDENTS.NAME (Fir"" Middle. Lasl, Sulll,) 2. SEX '" ~., OA.T~. qt~..Ei{I;,~..(I.1~"D'y, Yr.)
<br />Ra ond Louis Molcz k Male June 2, 2008.____
<br />'. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH Sa. AGE.La'l Blrlhday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo.. O'y, Yr.)
<br />(Y".) MOS. MINS.
<br />
<br />Spalding, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />78
<br />
<br />
<br />September 3, 1929
<br />
<br />6a. PLACE OF DEATH
<br />
<br />725-01-5165
<br />Bb. FACILlTY.NAME (If not inSlllution, give slreet and number)
<br />
<br />~:
<br />
<br />IJl. Inpatienl
<br />
<br />~; 0 Nursing HomBlLTC lJ Hospice Facility
<br />
<br />o ER/Ol,llpalienl
<br />
<br />o Oecedent's Home
<br />
<br />St. Francis Medical Center
<br />
<br />Grand Island
<br />ge. RESIDENCE.STATE
<br />
<br />68803
<br />_'-';;:COUNTY
<br />
<br />__ Hall
<br />
<br />o W\ 0 Olher (Specify)
<br />
<br />-. .. =CO~:Y;~OEATH
<br />
<br />--~=rT:WNGran~ I8lan.~
<br />91. ZIP CODE
<br />
<br />
<br />68801
<br />
<br />99. INSIDE CITY LIMITS
<br />
<br />tlil YES 0 NO
<br />
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />420 W Stolley Park Road
<br />100. MARITAL STATUS AT TIME OF DEATH !ill. Morrlad a Never Married
<br />
<br />lOb. NAME OF SPOUSE (Flrsl, Middle, La.l. Sum,) II wile, give mald.n namo.
<br />
<br />o Married, but separaled 0 Widowed D Divorced 0 Unknown
<br />
<br />Adeline Adnell Sawicki
<br />
<br />11. FATHER'S.NAME (Firat, MldOle,
<br />Moloz k
<br />13. EVER IN U.S. ARMED FORCES? Give dalo' 01 ,otvlee II yo.. "a.INFORMANT-NAME
<br />
<br />Lasl.
<br />
<br />Sullix)
<br />
<br />12. MOTHER'S.NAME (Firs I, Middle,
<br />Dorothy (HMI) Kowalski
<br />
<br />Maiden Sumame)
<br />
<br />o Crernallon 0 Enlombmerll
<br />
<br />16d. CEMETERY, CREMATDRY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />140. RELATIONSHIP TO DECEDENT
<br />
<br />Wif~__.._.
<br />lBc. DATE (Mo.. Day. Yr. )
<br />
<br />Ju:p.e 5, 200L
<br />STATE
<br />
<br />No
<br />
<br />
<br />Molczyk
<br />
<br />]'6bLlC7fle0
<br />
<br />tit8ufleJ
<br />
<br />o Donation
<br />
<br />a Romoval
<br />
<br />a Othor (Speelly)
<br />
<br />Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br />
<br />18. PART L EntBr Ihe chain 01 Avenl!l.--diseasss, injuries. or complicalionS--lhal dlreclly caused lhO dealh. DO NOT onler lermlnal even Is such as ca(diae arrest,
<br />teSpl(Blory IilrrElst, or ....enlricular Iilll'lIIslion wittlOulsnowin~ lhe eliology. DO NOT ABBF-tEVIATE, Enler only one cause on a line. Add addlUonalllneSIJ necBssary.
<br />
<br />
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (S"oal, Cily O<Town, Sle'o)
<br />
<br />Kleine Funeral Home, 3213 W North Front St., Grand Island, NE
<br />.~'~ ." ';1, ':1A. \""." :1,re ":;.jl
<br />
<br />IMMEOIATE CAUSE:
<br />
<br />I
<br />
<br />I onsello death
<br />I
<br />I
<br />
<br />___L_~__"
<br />I onsello deslh
<br />I
<br />I
<br />I
<br />I onsello death
<br />
<br />IMMEOIATE CAUSE (Fln,1
<br />dlllisssa Dr condition reil.llllng
<br />In deelh)
<br />
<br />~~,_ggngestiv~.1L~art Ia.ilure
<br />OUE TO. OR AS A CONSEaUENCE OF:
<br />
<br />Sequentl,lIy lIal condlllOno,1I (b) Car iI i om.y 0 pat h:'i
<br />any, leading 10 tho .au,ell'ted ---DUE TO, OR AS A CON~EaUENCE O~:
<br />on line B.
<br />En,e, the UNOERLYINO CAUSE
<br />(dl.aa., 0' InJu'y thetlnm,lod (c)
<br />the evenls. resulUng In death)
<br />I.ASI'
<br />
<br />DUE TO. OR AS A CONSEOUENCE OF:
<br />
<br />onsello death
<br />
<br />~ P?~~nonia, C~~onic Renal Failure
<br />16. PART II. OTHER SIGNIFICANT CONDITIONS.Condltlons contributing 10 Ihe daalh bu' nol ro'ulling In Iho unaerlylng C'u'O given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED7
<br />
<br />o HS 0 NO
<br />
<br />20.IF FEMALE;
<br />
<br />21 a.M~ER OF DEATH
<br />IfI ~alural 0 HomicIde
<br />
<br />o NOI pregnant wllhin pa.sl year
<br />[J Pregnant at time 01 death
<br />[] Not pregnanl, but pregnant within 42 days or dealh
<br />o Not prBijnanl, bur pregnanl43 days to 1 year befOre dealh
<br />o Unltnown II pregnanL wllnln the pasl year
<br />. 22.. DATE OFINJURY (Mo., Day. y;";'-~oF-iN.iURY
<br />ttl~:"J. m
<br />t:.c.' ~--"'-"J:---'-"""-"--"--""
<br />i i 22d INJURY AT WORK? 22a DESCRIBE HOW INJURY OCCURRED
<br />~ ".) D' 'S 0
<br />~~(lI~~~f- f t=: NO
<br />
<br />1'1; 221. LOCATION OF I~:;~;~Y . 3TREE-:;-;~UMBER. APT. NO.
<br />~
<br />
<br />m.~,,1t 230. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />~:IWNl ~~ JUNE 2, 2008 !'~ ~
<br />:r~~V"iJ ]iil13
<br />:~\~~ :!! ~" 23b. DATE SIGNED (Mo., Day. h) 230. TIME OF DEATH ]1 if ~ >-
<br />
<br />~jft~;i ~';~ JUNE 4 2008 13: 22 pm ~ a:UJw d
<br />
<br />~~l', 8.c ?i}i:). To &'best or1ny know lodge, h Occurred allhe lime, cJale and place 8 Z: 24e, On (he basis 01 examination andJor InvBsligalion, In my opinion dealh occurred at
<br />~;';i1t~l/: .8 ~ ~ d,/~ '~9lJse(s) Gta . (~/;ur~ and TI~1-!~ ,~~ J^ 1115 5 !tIe lime, dale and place and due 10 thecause(s) Slaled, (Signature and Title) T
<br />ti~!% ~ ,!! ~ L-.."VUl (7'l'!. pvw'/ ~ !l< ~
<br />!i:~~1 <l u
<br />
<br />i~~'~;;5. DIOTOBACCO UJf CONTRIBUTE OTHE DEAT~? 26.. HAS ORI>AN OR TISSUE D~ION BEEN CONSIOERE07
<br />
<br />;oJ1i1~ a YES .Ilf' NO a PROBABLY a UNKNOWN a YES d"NO
<br />~~), 27. NAME, iiTLEAND ADDRESS OF CERTIFIER (PHYSICIAN:'coiloNER'S p~YSlci;';N OR COUNTY ATTORNEY) (Typo or Prlnij"'
<br />I~:"\ . .
<br />,,,,,,,,~ Willlam J" Lawton Fa dIe
<br />
<br />o AccldentQ Pending InvesligaUol'1
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />o DrivBr/Operalor
<br />
<br />o Passenger
<br />
<br />o P6deslrJan
<br />
<br />21e. WAS AN AUTOPSY PYWORMED?
<br />o YES ~O
<br />
<br />o Suicide 0 COUh:!" nol be delerminecl
<br />
<br />a Olhor (Speelly)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />COMPLETE CAUSE OF DEATH7
<br />
<br />a YES 0 NO
<br />
<br />22c PLACE OF INJURY.AI home, larm. sir.". laClory, olllca bUilding, conOlruellon Silo, .Ic (Spaclly)
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />2'~'~0r(€rD~;' Yr.)
<br />
<br />
<br />24C. ~~ UNCED DEAD (Mo.. Oa1, Yr.)
<br />
<br />24b. TIME OF OEATH
<br />
<br />m
<br />
<br />2.d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />260. WAS CONSENT GRANTED?
<br />
<br />Nol Al'!'lie.a.b}e il 26, Is NO 0 YES a NO
<br />
<br />26,. REGISTRAR'S SIGNATURE
<br />
<br />
<br />and NE 68803
<br />
<br />~
<br />
<br />JUN 1 0 2008
<br />
<br />HHS.6111/03 (550B1)
<br />
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