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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUIrfAN SERVICES
<br />SYSTEM, rr CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAl:i.R6~FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST~~_6110N,'WHICH IS
<br />
<br />:TELE;~::=TORYFORV1TALREam= ...t/'iIl,f.~
<br />DEe 5 2000 200 90 2009'. "~i~st.4Ntslf~:E;g~:
<br />LINCOLN, NEBRASKA HEALTHANiJHU~N SERVlCES'S.TEM
<br />
<br />~ , .,.:::.:.-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEAL TII AND HUMAN Sl:ia\1CiS'WANCS.AND SUPPORT
<br />VITAL STATISTICS . ,','[., .__,~,.
<br />CERTIFICA TE OF DEA Tl-I '-:ct:-.;.~, ,"
<br />
<br />'-DECEDENT, NAME ~~-- --FiRsT'
<br />
<br />
<br />Barbara Miller
<br />
<br />~~
<br />
<br />J DA-f~ SF l)F.A'T-H-'-,A,,(),-;m"7l.";,ni';~,:lr}
<br />
<br />.,- M'i5-D~C'E"""
<br />
<br />I.A~; I
<br />
<br />Jack Laurence Bydalek
<br />
<br />1\ Cli~' ANO STATE Of BIRTH Ilfnofm USA namecot.m';YI----r~ACiF L,,!'>t B;"rlhrlfl.' ~ UNDER' YEAR
<br />
<br />Ashton, Nebraska _~v'b4 '" MOS DAYS
<br />
<br />
<br />7 SOCIACSF,CURT1YNUMBER - ---- AM Pl.ACfOFDEA1H
<br />
<br />Male ..
<br />
<br />November 23, 2000
<br />
<br />5'~5A1E-{~)F Blf.H H iMonth 0,..,;- ~;~~rI
<br />
<br />.",~~J?_~_~~e~__~ I
<br />[]
<br />D
<br />D
<br />
<br />1936
<br />
<br />506-40-1784
<br />
<br />HOSPITAL
<br />
<br />NurSHllj HOlm!
<br />
<br />OTHER
<br />
<br />Inpatient
<br />
<br />Bb FACILITY.. Name
<br />
<br />(If not In_r;tttution, give street and ,~;;;ije-;j"~.''''--''''
<br />
<br />ROSlllon(.('
<br />
<br />f.R QUlpahE!nt
<br />
<br />St. Francis Memorial Health Care
<br />
<br />Be C1!v. roWN OR LOCATION OF DEAn;----.
<br />
<br />OOA
<br />81:.' COUNTY or DE.A'l-~i'""-_.-
<br />
<br />OlhOr iSfJOCdl'/
<br />
<br />Grand Island
<br />"9a RESIDENCE, STATE
<br />
<br />
<br />9d STREET AND NUMBEH (Inc:ludinq Zi{l C(]!1iE'). -----r. ~~p. IN51DF CITY t.IMIlS
<br />. tltl803 :
<br />Sheridan Ave. -.1__ve5 KJ N,:,_P
<br />
<br />13 NAME OF SPOUSE !II wdt~ 9(1j1? maiden l1i"lmel
<br />
<br />Nebraska
<br />
<br />Hall Grand Island
<br />
<br />10. RACE
<br />
<br />etc.llsooe,IyiWhi te
<br />
<br />" ANCESTRY If:! 9
<br />15pec,ly! American
<br />
<br />14a JSUAL OCCuPATION fGlv~ kind of worlr: done during mo~f
<br />of worlo.'lng life. f!ven if retired)
<br />School Teacher
<br />
<br />It;. EOuCA nON l$peClly only tll!::ihe~1 !-jrade ClJlflplel8dl
<br />E'emen'IY,if SecoMary 10, 12\ COII~+: .j "'ir
<br />
<br />-'""'00'"'--' ----~MAID[N SuRNAME
<br />
<br />14b
<br />
<br />Education
<br />
<br />By~:~e~-T7 'MOtHEA
<br />
<br />lB, WAS O(CEASEO EvEH IN u,S, ARMEi)F5R~.~--- 11% INFORMANT NAMF
<br />IVe> no'~Okl I" yes g,ve w", aM dal.' 01 '."'IO.sl Barbara Bydalek
<br />
<br />16:'7.<\ THER ' NAME
<br />
<br />FIRST
<br />
<br />MIDOIF
<br />
<br />Clara
<br />
<br />Nowicki
<br />
<br />Cyrus
<br />
<br />'90 INFORMANT
<br />
<br />ISTREET OR R F J NO CITY OR TOWN STAT!= ZIP)
<br />
<br />MAILING ADORESS
<br />
<br />,-' 2309 N. Sheridan Ave. I
<br />";i5--E'i~'MER ' SIGNATURE & LICENSE NO
<br />
<br />. )') {"(.( i/7 Z("O. i.(",(' r:/2(;:
<br />i <,a cuNERAL HOOE . NAME
<br />
<br />i Apfel-Butler-Geddes ~."on D D""al""L
<br />122b ,uNERAL HOME ADDRESS ISTREET OR R,F.D. NO-:"CilV OR TOWN. srATE.ll';I---'---~-~'
<br />, 1123 W. 2nd Street, Grand Is1and,Nebraska 68801
<br />
<br />~~m"c;c f{'Q9~\"~
<br />
<br />, DUE TO, OR AS A CONSEOUENCE OF
<br />
<br />68803
<br />
<br />)- .3 l' 2~MfTHOD OF D[~S:]OS Tlr" : ,"'" [)^rr'--' '--'--"----1"< CEME-wi"OR(;ReMAl-,-if1i NAME
<br />
<br />C' LXJ OC'ol . H>'''''" L\JOY~_,??L 2000 G~al1d ~~~_~I:1d Cemetery
<br />I 21 t' U:.METEAv OR CREMA TORY LOCATION ell Y (lH lOwN STI\, '1"(
<br />
<br />Grand Island,
<br />
<br />NE.
<br />
<br />Grand Island,
<br />
<br />NE.
<br />
<br />~~t:~~:w~ 2R L~ \~~I~;;
<br />
<br />Wee.{
<br />
<br />hlterv<:ll tH!tw~~rl orl:.;~:t rl~,(j /1(;<11'.
<br />
<br />// Q/
<br />, --------,-"---~,~--"--
<br />~ tnlP.rviil bf!!wi:!er' onse' rlllll d!,'dlll
<br />
<br />bl
<br />1-31
<br />I
<br />
<br />..,...----
<br />
<br />Ibl
<br />nllf. Tn 09.AS,AC,.ONf;.t.Q:I.;HICEor'.--
<br />
<br />~.'._-~_._-'._",-~--,=:-=---=",",~~_..;;.'-
<br />._,__.._~.,~ '., '~,._.~'___. ,~ ., _.. __ __~.......--r-- -._.,_,._ -
<br />
<br />_"................~--r-=--~,~=~~"':""-=-~---==-.~~"~-...,~ ..
<br />I lr1tCr'J,11 1:,'ClwCI:r1 on:,e~ "rlG (11~.,!I'
<br />
<br />lei
<br />PAH I aTHER SIGNIFICANT CONDITIONS . CO/'l~:hMr'lS contnbullng 10 !he death bul 1'101 reiai~d
<br />
<br />"
<br />
<br />I
<br />PART III IF FEMALE::. WAS fHEi=tE: A I ~4 AuTOP'Sv 1 2$ WAS CAS[REFERRED TO MEDICAL
<br />PREGNANCy IN THf PAST 3 MONTHS'" I ~ EXAMINER OR CORONEq.!
<br />
<br />(Ag(J~ 10.:"4) Yes n No n Yes n ~ Yes n No lki:.__
<br />1 26d DFSCRIBE HOW INJURV OCCuRRED
<br />
<br />i
<br />~ .
<br />'E I 26a 2Gb DATE OF INJURY (Ma.. Day, Yf.) 26c HOuR OF lNJUf=lV
<br />
<br />......... I [J Acc>den, 0 UndeWmrned M
<br />
<br />~. 0 S(JI(:tQe D P~ndlng 258 INJLJRYATWORKiT6f PlACEOfiNJURY Al home farm strl'!l'!l fnCIO;V -'1.26q LOCATION
<br />_ (1!1Il':e bUlldHiQ el( l'ip~ufy' I'
<br />o Homli;lda InveSlIgatlCln Yes [J No D I
<br />
<br />~ --,----- 27a 6ATE-6f~DEATH (MO Oay Yr.j ~ -~ ~~- ----- - --i~nATESIGNED-(M() D~v l'rl
<br />
<br />EiJ d /I ( ",;!! I
<br />~ Il?: 27b 11 f' ~, 2&-"'PAONOUNCED DEAD IMo O.y. Yu
<br />~ !Ii !~~g
<br />I .lIf M 2:'q
<br />.? j 270 TO the best 0 my knowledge death OCc:urre .C! ii ;.) 28e On It!!:: oasis olexaminalion aM or InIJOslIgaliof"), In my opinIon dealt OI~ClJrred al
<br />
<br />t-1: IS'::~t:::~~:I~:~1 ~ .. ',_______. _ w___... ,?, _ ~ IS'::'::: .~:.I::::ce and 0".'0 100 cau~~'~::I~~~_~___.___,
<br />
<br />',29 DID TOBACCO USe CONTRlaUTE TO THE EATH? :)0,' HA$(JRGAN OR TISSUE DONATION BEEN CONSIDERED' ~rOb WAS CONSENT GRANTED?
<br />
<br />e~ 13, NAME~D:;:RESSOF~RT~:ER IPHV~:::::;RSPHVSICIAN6R--'-;6UN1VA1TO~lv,V~;,oeo,p,,~) - ,__.u___ -- q-~~. -- ~
<br />I '.
<br />i Sltkl Copur M.D. 2116 W. Faidley, Grand Island, NE. 68803
<br />~ ~"".,- ~J~;'=I=:W"D~c:1ioo_____
<br />
<br />STReFT OR R F,D, NO
<br />
<br />CITY 0'1 TOWN
<br />
<br />~T;\Tf:
<br />
<br />28tJ, TIME OF lJEA T H
<br />
<br />-~_.
<br />
<br />2Bd. PRONOuNCED DEAD
<br />
<br />(HO(lrl
<br />
<br />M
<br />
|