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<br />STATE Of NEIIlASKA-OEPARTMENT Of HEALTH
<br />BUREAU Of VITAL STATISTICS
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<br />CERTIFICATE OF DEATH~> J~(',
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<br />r O'~U>tNl-"_f "1ST "'OOlE lAST I'" IOA""'O'.,H'.... 0';"y,)
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<br />I b~;, ~~.J('~~~).,O<, f!':'=~~~!~~f~;';t;;, ~~~. .._~~~S~~ :,:r.<:..- , :;:!~~}~~: I ~d~ I ~~: ~~, Of ;,~,~T..., 0." y>!
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<br />. " Poli;>h.. l'~! 160 75 16. : i.. : ,\leoember 20, 1906
<br />CIty AH fAU -Of 8flrH f1lll'01 il'l V s.-~_, ;cmlfN Of ""'W.T CdUNrtyl~htt!D, NfVfl '"""ftn, , _ ! NAM! OF SPOU$t ((I wit.. fII.... "'Did.. "-Of")
<br />fl<lQ4 'c~"/l1'l'1J I jWltlOWf-D, vIVOICEDfSp",ify) I'
<br />, ' ~~a~ka !9 USA 110. Harried t1 Stella Kosmi~ki
<br />soc,." SlC~tfY NUMatt !~/S~.~~~~::~ ~;:;:~td o! "0'. do_ dut."g -;-:~ I (INO Of 'U~NlSS ot INDt.\STJY I COUNn Of DEATH
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<br />11 _ jUa, 2etired farmer ;f ;'.~.' 113b FarminJ; It40, Hall
<br />CITY, fOWl" Oll.oc.nON Of QUTH ! ;~:,~ c.;: ;:~~; I :::::..~ ~do.:':e:.~7STlTU"0H - 1'40_ Iff !tot in eillt.f, I ~..=~J:Th~~~w,.t
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<br />1,,< Yes i... 3t. ~'r'lncis JiIedical Center !... In'Odtient
<br />, : CITY, lOWN 01 lOCATiON ! stUff ,,~ NlJ~BU IIHs~'Ct-n-uA!\n$
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<br />;1'11 :'$< Gr311d Island I". 4304 W. Capital Ave. ".. re~... .
<br />MlOi)l LAST ! MOfHtl - MAIOEN NAM! fllSl MfOOLE ~
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<br />~\QJj;era : 11 Eleanora. Piontkowski
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<br />... II No ! ,,{ Ca.Di tal Ave. Grand
<br />r aU'IA.l, CT~.-'otl. R~ootO'>'OIIOATl ,lOCATJON CIl"fOITOWN $TAU
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<br />WHEN JRIS COpy C~RRIIS THE RAISED SEAL Of THE NEBRASKA
<br />STATE DEPARTXEWf GF "EALTll, IT CERTIFIES TUE ABOVE TO BE
<br />A TIUll!: COPY OF ;.N' OKIGINAl RECORD ON FILE WITH TUE STATE
<br />DEP~~~ENT 0F ~~AL1ll, BUREAU OF VITAL STATISTICS, WHICH
<br />1 S rHE~.LEGAL J).t5~"OSlTORY FOR \ HAL RECORDS.
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<br />DIRECTOR OF VITAL STATISTICS AND A$SISTA.~ STATE REGISTRAR
<br />LINCOL~, NEBRASKA ISdued September 3. 1982
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