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<br />",-,:!"J.
<br />
<br />WHEN THIS Copy CARRIES THE RAISED SEAL OF THE NEBRASKA STA TE D.EElfRTN/UJ~QF Hl!Jt(Tl!::.,
<br />"CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECOR.!lFijiJi~l~~ SrA""~~-
<br />DEPARTMENT OF HEAL TH, BUREAU OF VnAL STA T1STICS, WHICH 1!}ffNf!c'J!rJAL I?lf!!QS~ FOR
<br />VffAL RECORDS. .ff~;_:C'7- --j!c jf;~t'"..~. \:-:-:-~~
<br />~-..:~~ - - ":-~-==-
<br />..,;: -= . "--".
<br />DATE OF ISSUANCE 200900900 i "',~:_:, .-;:;.:~, _~
<br />JUN 1 1995 #AIf~: clj~.. lJlfiiFTOR
<br />LINCOLN, NEBRASKA 1I~u.. f'JF"1l1fAL-=J!.'ht!ISTICS
<br />~ - - - 1"'.......... -..~-
<br />STATE OF NEBRASKA - DEPARTMENT (5f.-tiE'"Al~ ~":-'....;;.--
<br />BUREAU OF VITAL STATISTICS --':,-,,,,..:~-'
<br />r"
<br />CERTIFICATE OF DEATH
<br />
<br />, DECEDENT. NA"E
<br />
<br />FIRST
<br />
<br />"'DDlE
<br />
<br />LAST
<br />
<br />2 SE'
<br />
<br />3 DATE. Of DEATH ,.Mor!- [J,), Yearl
<br />
<br />Frank Jos
<br />4. CITY AND STATE 0' BI~TH IHnot '" u.SA. name """"",I
<br />
<br />
<br />Kotre
<br />50 AGE . Last e."""", UNDE~ , yEAR
<br />IY".I 50 "OS' DAYS
<br />88
<br />
<br />1a1e
<br />UNDER , 0.4 y
<br />5c HOURS "'NS
<br />
<br />
<br />1995
<br />6 DATE. OF BIRTH IMDnln O,j~ Y8a;I'~-~----------"""
<br />
<br />Palmer, NebJ;_~ka
<br />~ 7 SOCIAL SEoCURTIY NU"BtR
<br />'1
<br />... 505-09-8026
<br />:; 81>. 'ACILlTY-Name (Knot'"'""""",.IJ'.._.nd~J
<br />
<br />~ Grand Islam Veterans Hcl'rv:
<br />- ~.-'C!T.Y TOWNCA~,HO"'QF'~H
<br />
<br />sa. PLACE OF DEA T H
<br />
<br />Februarv_~l~QL........._._.
<br />
<br />HOSPITAl 0
<br />o
<br />o
<br />
<br />..,..... 2T!,~
<br />E~~
<br />
<br />IRI Nu"'ng He"",
<br />o Ae510ence
<br />
<br />o 0Ihe'i5.oec""
<br />
<br />OOA
<br />
<br />elC.)IS<>oc"Y1 ISI>e<"Yj
<br />White Czec<oslovakian
<br />... USUAL OCCUPATION !o...."'" 01_ dona duting ""'" 1011> KIND OF auSlNESS INDUSTRY
<br />_I OI_"'9Ii11._t_1
<br />Travelin Salesman
<br />-i '6 FATHER - NAME FIAST MIDDLE
<br />4 .
<br />41 Lams
<br />. 'a. WAS DECEASED' EVE~ IN U.S. ARMED FORCES'
<br />(Yes. no. Of" unK.) In yes, give war and dales ~ S8fVices1
<br />Yes 1 -27-43 to 11-1-45 Agnes Kotrc
<br />IIlb INFORMANT MAILING ADDRESS ISTREET OR A.FD. NO.. CITY OR TOWN. STATE. ZlPI
<br />
<br />
<br />... INSIDE CITY LIMITS
<br />
<br />Grand Island.
<br />9&. ~ESIDENCE - STATE
<br />
<br />(tncwmglwC_, .. INSIDE CITY L1"ITS
<br />
<br />Nebraska
<br />
<br />68803 Y.. W No 0
<br />
<br />13 NAME OF SPOUSE IH _ ".... "",.den ""mil!
<br />
<br />es Cadek
<br />15 EDVCA TION ISpec,1y only h~ 9'- <"""""led)
<br />E~.nlaryor~fY fO-121 ~ il.4()t~~1
<br />
<br />"'DDLE WolDEN SURNAME
<br />
<br />. J~anka
<br />
<br />
<br />Grand Island, NE.
<br />
<br />68803
<br />
<br />21.. "ETHOD OF DISPOSITION 2'b. DATE
<br />
<br />2'<. CE"ETERY OR CRE"ATORY NAME
<br />
<br />A fel-Butler-Geddes DCtomoliool 0-
<br />221>. FUNERAL HOME AOORESS IST~EET DR R.F.D. NO.. CITY OR TOWN. STATE. ZIP!
<br />
<br />IX] Bunal 0 """""'al r-ta 27, 1995 Westlnwn Merorial Park
<br />21d CEMETERY OR C~EMATO~Y LOCATION CITy O~ TOWN STATE
<br />
<br />
<br />NE.
<br />
<br />1123 West Second,
<br />
<br />Grand Island, NE. 68801
<br />IENTE~ ONLY ONE CAUSE PER lINE FOR lal. Ibl. ~D 1<11
<br />
<br />~al between on~ afllj death
<br />
<br />2J IMMEDIATE CAUSE
<br />PART
<br />I
<br />
<br />.
<br />.
<br />.
<br />i
<br />
<br />la,
<br />DUE TO. DR AS A CONSEOUENCE OF
<br />
<br />Caroiac Arrest
<br />
<br />Imrediate
<br />
<br />lnIer"val bittMen onset a~ ~ath
<br />
<br />... Hyperca1cania
<br />DUE TO. OR'As A CONSEOuENCE OF
<br />
<br />4 r.bnths
<br />
<br />IniI;!r"otBI betvwMn onset ana dealt!
<br />
<br />Hultiple Hyelaua
<br />
<br />10)
<br />OTHER SIGNIFICANT CONDITIONS . ~s <_ng 10.... dO." ""'"'" "".Ied
<br />PART ..1
<br />II Prostate CAfHeningiorna
<br />
<br />2fir>. DATE OF IHJU~Y (Me.. Day. Y'J 2tlo: HOuR Of INJURY
<br />
<br />
<br />3 Years
<br />
<br />26a
<br />
<br />o AccidofO 0 U-""no<I
<br />o SuiC"'" 0 Pono'ng 26e INJURY AT WO~K
<br />o Hom.:"'" In.._""" Y.. 0 No 0
<br />27.. DATE OF DEATH (Mo.. Day. Yf./
<br />
<br />26g. LOCATION
<br />
<br />ST~EET OR RF.D. NO
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />280. DATE SIGNED {Mo 0.., Yo
<br />
<br />280 TI"E OF DEATH
<br />
<br />Na 24 1995
<br />
<br />'"H
<br />h~~
<br />11"'6
<br />~L
<br />8 ~
<br />
<br />"
<br />
<br />i ja
<br />af~
<br />
<br />.
<br />
<br />
<br />May 25, 1995
<br />
<br />"
<br />
<br />27b. DATE SIGNED {Me Day Y'I
<br />
<br />2llc PRONOUNCED DEAD (Mo. Day, Yf./
<br />
<br />26<l PRONOVNCED DEAD {Haull
<br />
<br />28&. On the basis of eX,iilmlnahon tlna.Of IflYe'!ibgabl)n, In my ()pII"IO"l 08alt'l OCcurred at
<br />the time, daM .;tnd place ana aue to _ c:;.~sl slated.
<br />
<br />30." WAS CONSENT GRANTED'
<br />DYES Q NO
<br />
<br />Duane E. Baker, M. D., Grarrl Island Veterans Hane, Grand Island, NE 68803
<br />32a REGISTRAR
<br />
<br />
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