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<br />STATE OF NEBRASKA
<br />
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<br />1, DECEDENl'S-NAIIE (FI..~
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH ANP HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASMifD~~~tlT OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY~.!i~J~:~T~~ ,~_
<br />
<br />DATE OF ISSUANCE .7~~ tJOJ:"~~~'
<br />
<br />~, St'ANLEY S, ~COOPER , " .. "
<br />, ~~lST6Nr;'5. T~-rEf.?' EGI$TfMR....
<br />.' QEPARTJ!JE1lJ; (i)fJ.,HEtJL If-! ~p.lCj
<br />, H!J.M.AN SERVICES, . .:.
<br />-\::':;. '.;1. ,"""''''",.'-,,:. "'... .
<br />
<br />STATE OF NEBRASKA - DEPARTMaE~~ bFDEATAtiD HUMAN 'SERYI.~~~~{~ ~': ~'G '8 ;". 29820
<br />
<br />2. SEX '< ~,' , ~ ~1'E~DI!A~~lMo..DoIy,vr.)
<br />Female" \', "Se'Pfembe~ 22, 2008
<br />Iic. UNDER 1 DAV l. DAlE OF BIRTH (110.. Day, Vr.)
<br />HOURS I MIN&.
<br />July 23, 1915
<br />
<br />OCT 0 1 2008
<br />
<br />200900182
<br />
<br />LINCOLNLJj,gJlRA$~A
<br />
<br />Iq
<br />~
<br />
<br />Mlddl.,
<br />
<br />L.aa~
<br />
<br />__I
<br />
<br />Josephine F Kaminski
<br />
<br />4. ell'< AND STATE OR TERRITORV, OR FOREIGN COUNTRV OF BlRTl1
<br />
<br />Fullerton, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />93
<br />
<br />~NDER 1 YEAR
<br />MOS. I DAYS
<br />
<br />$a. AGE-Last Birthday
<br />
<br />(Vra.)
<br />
<br />524-22-8628
<br />81>. FACIUl'<-NAIIE (If not lnattadlon, II.... a_ and numbarl
<br />
<br />IL PLACE OF DEATl1
<br />tI2llfII6I.i 0 In",-
<br />
<br />o ERIOulpallanl
<br />ODOA
<br />
<br />QIJ:Wt.1l!I Nuralng HomaIL TC
<br />O_a-
<br />
<br />o OIhao1st-1fY)
<br />
<br />o HoapIca Facility
<br />
<br />....
<br />" I
<br /> ~
<br /> II.
<br /> ~
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<br /> Q.
<br /> e
<br /> 0
<br /> (J
<br /> GO
<br /> lD
<br /> {!.
<br />
<br />Wedgewood Care Center
<br />
<br />8c. CIl'< OR TOWN OF DEATH (1nc:lu<Ie;zlp Coda)
<br />Grand Island 68803
<br />
<br />led, COUNl'< OF DEATH
<br />Hall
<br />
<br />8a. RESlDENCE-8TATE leb. COUNl'< I Be. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />gel. STREET AND NUMBER I'" APT. NO. III. ;ziP CODE
<br />316E. 15th 68801
<br />1Oa. MARITAL STATUS AT TIME OF DEATH iii ~1ICt 0 Nevar MarrllICtj 1Ob. NAME OF SPOUSE (Flra~ MlddlO, L.aa~ __)If _, gI... ....JdOn -
<br />o MarrIed, but ..parated 0 WIdowed 0 Divorcad 0 Unknown Vinrent Kaminski
<br />11. FATHER'$-NAIIE (Flra~ Middle, L.aa~ sums) 112. MOTl1ER'8-NAME (Flra~ Mleldla, MlIldOn Sumorna)
<br />Andrew Zauha Catherine Czamick
<br />
<br />Ttg.INSIDE ell'< UMITS
<br />00 v.. 0 No
<br />
<br />CJrrITOWN
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<br />14b. RELATIONSHIP TO DECEDENT
<br />Dauahter
<br />11e. DATE (Mo., Day, Vr.)
<br />Seotember 25, 2008
<br />STATE
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glva dOIaa of uMea If VOL 1... INFORMANT "NAME
<br />
<br />IV.., No, or Unk.1 ND
<br />15, METHOD OF DISPOSITION . .
<br />iii 8."" ,Ollonatl.. (,
<br />Dc""""""" 0 -...... ""
<br />o Romoval 0 OIho<1spo<:Ky'
<br />
<br />Diane Ruzicka
<br />
<br />1eL~;E,,:-8;:A:~;~7 (11~1u:.. )
<br />
<br />1ed. CEMETERY, CREMATORYllR OTl1ER LOCATION
<br />
<br />1181>. UCENSE NO.
<br />
<br />/Ot)~
<br />
<br />Wastlawn Memorial Parl< Cemetery
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Stra~ City or Town, S_)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />NebraSka
<br />1 17i>. ZIp Code
<br />68801
<br />
<br />CAUSE OF DEATH (See Instructions and examples)
<br />
<br />lIA>IAl..-",
<br />
<br />...,....,...,....... .r........,.....fIlj__.ut .._.8........"".
<br />
<br />Ent8t Old)' one ause on . Une. Add........ ...... .. ftHIIIIMrY.
<br />
<br />,~.-
<br />
<br />
<br />Wnoot to_
<br />
<br />IMMEDIATE CAUSE (Final
<br />dlso_ or condition ....ulllng
<br />In daath)
<br />
<br />~MEDlATE CAUSE:
<br />
<br />aJ C(N~() /J vI /V'-J c~ u."rrLf+-
<br />DUE TO, OR AS A CONSEQUENCE OF: \
<br />"--
<br />b) kf L-La:-, ~ r,~~'c..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />i~to-
<br />i onoot to _tit
<br />
<br />
<br />18. WAS MEDICAl EXAMINER
<br />OR CORONER CONTAClED?
<br />DYES ~
<br />
<br />SequanUally list cond,tiona. If
<br />any. loading to tlta c.uu listed
<br />on line a.
<br />
<br />Entar tIta UNDERLYING CAUSE cl
<br />(di..... or Injury tltallnlll_
<br />the ennts ..sulUng In _111) DUE TO, OR AS A CONSEOUENCE OF:
<br />LAST
<br />
<br />d)
<br />>48. PART II. OTHER SIGNIFICANT CONDI11ON&-Condltlona contrlbutlnll to tlte death but nil! ",,"ulllng In tlta und8f1y1ng ea...II....n in PART L
<br />
<br />u:
<br />W ~~F !IAAlE:
<br />ii:
<br />~ 01 pragnant wllllln p..t year
<br />W 0 pragnant lit time of death
<br />(J 0 NIl!_~ but pragnant wltltln <1.2 daya of_
<br />o Not pragnan~ but pragnant 43 daya to 1 yaar _ra death
<br />OUnknown If pregn.nt wllIIln IIHt _t year
<br />
<br />~1L ~R OF DEATl1
<br />~ral 0 Homicide
<br />o A<cldant D Pending _Uptlon
<br />o Sulcldo 0 Could not"'__
<br />
<br />21b. IF TRANSPORTATION INJURY "2ic. WAS AN AUTOPSY PERFORMED?
<br />o QrtY8l1Opet'OlOt 0 VES ~
<br />o P""""llOr
<br />o P_1rIan
<br />o OtItar (Spaclfy)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPlETE CAUSE OF DEATH7
<br />DYES ONO
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<br />'a
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<br />22a. DATE OF INJURV (MD., Day, Vr.)
<br />
<br />.122b. TIME ~F I~URY J .~c. P~CE OF IN~URV-At homa~ fa~ s_~ factory, ~ce building. c_on oIle, etc. (Spaclfy)
<br />
<br />-;:.'"
<br />
<br />. '~,..". ", .,;;,;;:;~,i
<br />
<br />22d. INJURV AT WORK7
<br />DYES DNO
<br />
<br />22a. DESCRIBE HOW INJURV OCCURRED
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<br />221. LOCATION OF INJURY" STREET & NUMBER, APT. NO,
<br />
<br />CrrvlTOWN
<br />
<br />STATE
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<br />ZIP CODE
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<br />230. DAlE OF DEATl1 (MD., Day, Yr.) :!ii
<br />
<br />~~ Cl/2 -z.lb8 ~O~
<br />
<br />i ~ .lbb. DATE SIGNED (MO;~, Vr.) 1'230. TIME OF DEATH i ~ ~ >
<br />~il:~ ~(L~/\)~ I O"l:;~oAm o.~-<:i
<br />o "'0 Ii '" ~ 0
<br />: €i 23<1. TO~IIHt~ _t of my knOwladlla, daatlt DCCU1jj~me, a'('d pi 8 iil z
<br />"" i Ond due e eausa(s:) ~ staled.. (';lSignotu.., It 11 i!:l
<br />{!.~ V 'f~8
<br />-< . ,')_... AI' --... 0..
<br />__TV ~v...... .........-............ U 0
<br />
<br />24L DATE SIGNED (Mo., Day. Vr.)
<br />
<br />:lAb. TIME OF DEATH
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo., Day. Yr.) Z4d. TIME PRONOUNCED DEAD
<br />
<br />""
<br />
<br />m
<br />
<br />2400. On IIHt _ of _nation and/or l_ptlon,ln my opinion _ occurrad
<br />at tIta Uma, date and pl_ and _ to tIto cauoa(a) ateted. (Signature and rllla)
<br />
<br />,~ l'n. DID TOBACCO US~TRIBUlE TO THE DEATH? "ia. HAS ORGAN OR TISSUE DONATION BEEN CON$lDERED7 I~. WAS CONSENT GRANTED7
<br />r-~. 0 VES QM:r 0 PROBABLV 0 UNKNOWN 0 YES ~ I Nil! Applleablolf 26a Is NO 0 YES
<br />
<br />\ .....J V. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNl'< ATTORNEY) (Typa or PrInt)
<br />Kenneth L. Vettel MD 2119 W. Faidley,^v Suite 400 Grand Island, NE 68803
<br />
<br />7I:#~-~. Ai I~.
<br />II/Ii, . vvvrv
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<br />
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<br />
<br />28L REGISTRAR'S SIGNATURE
<br />
<br />28b. DATE FILED BY REGISTRAR (MD., Day, Vr.)
<br />
<br />p
<br />
<br />SEP 2 9 2008
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