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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />SYS1EAf, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THEb~L RE~QBIH)NFILEWlTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VlTAL$rAn$~CHIS
<br />
<br />:::;::~:::::~TORY FOR VlTiLoo;O"2 9 3 7~Lit.-::.:'~...:~~B~i~N~ ....
<br />2/1 / 'tI'/'7JMlLeY~.Cf1pRR
<br />7 . 2004 _ISTA~mA~~R
<br />LINCOLN, NEBRASKA HEAL TH AI$ ~N SERVI'iESS'{lTEM
<br />-!'"=c ".=;:'-7r "~\"!;" ""',~,'~_..i....._~ fj"
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALlH AND HUMAN ~~,~~Bu,iPoRT
<br />
<br />CER~~s~~~~EA~"~;~!:-~-iL"::~~ 04 01553
<br />
<br />- " ~,,~.,~...
<br />" DECEDENT - NAME FIRST MIOOlE lAST .. Si::X , DATi:: OF OEATH IMonth. Day. Yoar)
<br />
<br />
<br />Lorraine
<br />
<br />
<br />7, 2004
<br />
<br />Marie
<br />
<br />Laskowski
<br />
<br />Female
<br />
<br />4, CITY ANO STATE OF BIRTH Iff not in U,S,A" nome country)
<br />
<br />Sa. AGE. Lasl Birthday
<br />(Y",I 7 6
<br />
<br />UNDER 1 YEAR
<br />5b, MOS, DAYS
<br />
<br />UNOE~ 1 OA Y
<br />5c, HOURS' MINS.
<br />
<br />6, DATE OF BIRTH /Month. Day.. Y.ar)
<br />
<br />Madison, Nebraska
<br />7, SOCIAl SECURTIY NUMBi::R
<br />
<br />September 7, 1927
<br />
<br />60. PlACE OF OEATH
<br />HO~P!T Al; 0 Inpatient OTHER: ~ NurSing Home
<br /> 0 EA Outpatient 0 ReSIdence
<br /> 0 DOA 0 Otl1er (SpeCtfVI
<br />
<br />505-38-0176
<br />
<br />8b. FACIliTY. Namo
<br />
<br />(If not institution. givti tiff"' and numbBrJ
<br />
<br />Beverly Healthcare-Lakeview
<br />Be, CITY. TOWN OR lOCATION OF D6A.Tl:L
<br />G ~ ali<t.1: s 1 an.d
<br />
<br />9a. RESIOENCE - STATE
<br />
<br />
<br />MAIOEN SURNAMi::
<br />
<br />~ t
<br />
<br />..-.j....,....",..i);. ,"'".
<br />
<br />9d STREET AND NUMBER -(Including Zip eMal
<br />
<br />90, INSIDE CITY liMITS
<br />
<br />Nebraska
<br />
<br />St. 68801
<br />
<br />Ya. 00 Na 0
<br />
<br />10. RAce.' (e.g_1 White. Black. American Indian.
<br />ate,IISaoeilyl Wh i t e
<br />
<br />American
<br />
<br />, 3, NAME OF SPOUSE (If w~, g'" mald9n noma)
<br />
<br />Ralph D. Laskowski
<br />
<br />140, USUAl OCCUPATION (Gi"" kind 01 WfJfk don~ during m()$/
<br />. ~IWfJfk/ng life. .""" H ,./Irad) H om em a ke r
<br />
<br />16, FATHER. NAME FIRST MIDOlE
<br />
<br />15, EDUCATION (Speelfy only nlgno" grado complotedl
<br />
<br />EJementary or Secondary /0-12) College 11-4 or ,5""1
<br />12 2
<br />
<br />Own Home
<br />
<br />
<br />lAST
<br />
<br />17, MOTHER'
<br />
<br />MIDDlE
<br />
<br />
<br />h
<br />
<br />Anna
<br />
<br />Freudenbur
<br />
<br />Ral h D. Laskowski
<br />ISTREET OR R,F,O, NO" CITY QRTOWN. STATE. ZIP)
<br />
<br />
<br />Island Nebraska
<br />21 ~ METHOD OF DISPOSITION 21 b, 0,0. TE
<br />
<br />68801
<br />
<br />.1e, Ci::METERY OR CREMATORY. NAME
<br />
<br />1071 00 Burlel o Romoval 11 2004 Crown Hill Cemeter
<br />.1d, CEMETERY OR CREMATORY lOCATION CITY OR TOWN STATE
<br />
<br />DCIlImlllion o Oono",," Madison, Nebraska
<br />
<br />221>, FUNERAl HOME AODRESS (STREET OR R.F,D, NO" CITY OR TOWN, STATE. ZIP)
<br />
<br />2929 S. Locust St.. Grand Island, Nebraska
<br />
<br />68801
<br />
<br />23, IMMEOIATE CAUSE
<br />PART
<br />I {al RENAL FAILURE
<br />DUE TO. OR AS A CONSEOUENCE OF'
<br />
<br />tENTER ONlY ONE CAUSE PER liNE FOR lal, {bl. AND {ell
<br />
<br />I Interval between onset and death
<br />I
<br />I
<br />I
<br />I Inrerval between onset and deatll
<br />I
<br />I
<br />I
<br />I Interval between onset and death
<br />I
<br />I
<br />I
<br />25. WAS CASi:: REFERREO TO MEDICAl
<br />EXAMINER OR CORONER?
<br />No X
<br />
<br />(bl RENAL MALIGNANCY,
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />1 '~
<br />
<br />{el
<br />PART OTHER SIGNIFICANT CONplTIONS . Condl1lons contributing 10 tho dlNllh but not ralat!ld
<br />
<br />II
<br />
<br />268.
<br />
<br />
<br />MULTIPLE MYELOMA
<br />26b, DATE OF INJURY IMo.. O.y, Yr.' 260, HOUR OF INJURY
<br />
<br />o Accident 0 Undetermined
<br />o SuiCide 0 Pending
<br />o - 1noe001g_
<br />
<br />260. INJURY AT WORK
<br />Y.. 0 No 0
<br />
<br />28g, lOCATION
<br />
<br />STREET OR RF,D, NO,
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />tti
<br />
<br />~~
<br />
<br />.7a, DATE OF OEATH (Mo., Osy, Yf.)
<br />February 7,
<br />27b, OATE SIGNED IMp.. Oay, Yr.)
<br />
<br />28<1. PRONOUNCW OEAD IHou,'
<br />
<br />28a, DATE SIGNED (Mo.. Day Yr.!
<br />
<br />2BO. TIMi:: OF DEATH
<br />
<br />2004
<br />
<br />"'I:;
<br />~~ z
<br />I ~ ~ 26c PRONOUNCED DEAO (Mp Day., Yrl
<br />~~2:i
<br />"'E~
<br />.sili~
<br />.2L
<br />8 ~
<br />
<br />M
<br />
<br />M
<br />
<br />
<br />o YeS
<br />
<br />~..
<br />
<br />31.
<br />
<br />ITy.po or Prlntl
<br />Ave., Grand Island, NE
<br />
<br />68803
<br />
<br />Wm.
<br />
<br />Lawt on, M. D. ,
<br />
<br />32a. ~EGISTRAR
<br />
<br />3.0. DATE FllEO BY REGISTRAR (Me., Day.. Yr.)
<br />
<br />FES 1 3 2004
<br />
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