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<br />STATE OF NEBRASKA
<br />
<br />~
<br />
<br />- fo/HEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT.H;Al'i1CrFtOMMy SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBFMSK/k~Rl1:1.EfJ; O.F HEAL TH AND
<br />HUMAN SERVICES VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR'Vl[A~.RE"qoIDs; '1/,. "i
<br />' N;:~S~ kr ,&"'~L"~c
<br />DATE OF ISSUANCE /~~..,.. _,.~
<br />S"AANLEY~ .I,:QOPER. ".
<br />AssisIA", frTAtEREGISTRA'R
<br />D&P,"(?TM"' NTOr. HI!AlTH A/ilD '"
<br />HtJr,JAN SERVICE:$.: :',.:/ ..'..
<br />, '~~"'. I'~./i"", , 'i .,,,; ',\ . '-
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<br />'i. "'J';: ';/ :,'?
<br />STATE OFNEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES FINAN CE~Nb,8UPPO~r,'8" . . 3' ,'1439
<br />CERTIFICATE OF DEATH . , ' u
<br />
<br />NOV 1 9 2008
<br />
<br />200903234
<br />
<br />~
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />1.DECEDENT'S.NAME (First. Middl.,
<br />Saraphonia
<br />
<br />Last!
<br />Osantowski
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Female
<br />
<br />3. DATE OF DEATH (Mo" D.y, Yr.)
<br />November 12. 2008
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Loup City. Nebraska
<br />
<br />5.. AGE.Last Blrthd.y 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />84
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo" D.y, Yr.)
<br />
<br />July 2. 1924
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-12-7106
<br />
<br />B.. PLACE OF DEATH
<br />
<br />1:lQ.SEJIAL:
<br />
<br />O1lnp.tI.nl
<br />
<br />QIJ:IEll: Q Nursing Hom./LTC Cl Ho.plc. F.cllity
<br />
<br />Bb. FACILITY.NAME (II not in.titution, give .lr..1 and numb.r)
<br />
<br />Q ER/Oulp.lI.nl
<br />
<br />Q D.c.d.nt'. Hom.
<br />
<br />St. Francis Medical Center
<br />
<br />Q 000\ Q Oth.r (Sp.city)
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />6c. CITY OR TOWN OF DEATH (Includ. Zip COde)
<br />Grand Island, 68803
<br />
<br />90. RESIDENCE.STATE
<br />Nebraska
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />XI YES Q NO
<br />
<br />9<1. STREET AND NUMBER
<br />1315 W. Koenig St.
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH Q Marrl.d Q N.v.r Marrl.d lOb. NAME OF SPOUSE (FlrSI, Middl., LaSI, Suffix) it wif., glv. m.ld.n name.
<br />
<br />Q M.rrl.d, but s.p.r'l.d ~ Wldow.d Q Divorced Cl Unknown
<br />
<br />1 t. FATHER'S.NAME (First,
<br />Frank
<br />
<br />Middl.,
<br />
<br />Lssl, Sulfix)
<br />Larchick
<br />
<br />12. MOTHER'S.NAME (Flr.l,
<br />Stancie
<br />
<br />Mlddl.,
<br />
<br />Msid.n Surn.m.)
<br />Gzehoviak
<br />
<br />13. EVER IN U.S. ARMED FORCES? Giv. d.tos of ..rvic.1f ye.. 14'.INFORMANT.NAME
<br />
<br />No Gayle Zach
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />~ Burial
<br />
<br />Cl Donation
<br />
<br />
<br />HER LOCATION
<br />
<br />116b. LICENSE NO.
<br />
<br />1/3aB
<br />
<br />CITY /TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />
<br />16c. DATE (Mo., D.y, Yr. )
<br />November 17, 2008
<br />
<br />STATE
<br />
<br />Q Cr.m.llon Q Entombm.nl
<br />
<br />Q R.mov.1 Q Olher (Sp.oity)
<br />
<br />Grand Island Cemetery,
<br />
<br />Grand Island, NE
<br />
<br />- .
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Slro.l, City or Town, SI.te)
<br />Apfel Funeral Home 1123 West Second,
<br />
<br />PART l. Enter the chain 01 AVAntSndiseases, Injuries, or compllcatlonsnthat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />r..piralory .rro.I, or v.ntricul.r IIbrill.tlon without .howlng the .tiology. DO NOT ABBREVIATE. Ent.r only on. O'u.e on .lIn.. Add .ddllion.1 line. If n.c....ry.
<br />
<br />IMMEDIATE CAUSE (An.1
<br />d"""'.. orcondltlon ...ultlng
<br />In death)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />~.~_~lJo...s.~ aCC:d.e~ l~~
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Soqu.nll.lly lI.t conditions, If
<br />.ny, loading to tho o.us.llot.d
<br />onlln81.
<br />Enterth. UNDERLYING CAUSE
<br />(dl..... or Inlury thst Inltlot.d
<br />the .vantllresultlng In d.ath)
<br />LAST
<br />
<br />..~~~
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />_l~
<br />
<br />I
<br />I
<br />I
<br />
<br />A. (fMl(~
<br />
<br />ons.t to dO'lh
<br />~~
<br />tA-~
<br />
<br />on..t 10 d..th
<br />
<br />ons~
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Onset to death
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS. Conditions contrlbuling 10 Ihe d..lh but nol resulling in tho underlying c.u.. given in PART I.
<br />
<br />_..~~L~ I
<br />
<br />20. IF FEMALE:
<br />~ot pr.gn.nl within p'.1 y.ar
<br />Cl pr.gnsntst time ot d..th
<br />Cl Nol pregn.nl, but pr.gnant wllhln 42 days of d..th
<br />Q NOI pr.gnant, bul progn.nl43 deys to 1 yoar bofore d.alh
<br />Q Unknown il progn.nt wilhin the p'.1 y..r
<br />
<br />Q Suicide Q Could nol b. d.t.rmin.d
<br />
<br />21b. iFTRANSPORTATION INJURY
<br />Q Drlv.r/Operator
<br />
<br />Cl P....nger
<br />
<br />Cl Pedestri.n
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />Q YES NO
<br />210. WAS AN AUTOPSY PERFORMED?
<br />
<br />Db -
<br />t-' ~J
<br />
<br />a.,.A-e..V\~
<br />
<br />21.. ~NER OF DEATH
<br />~N'lur'l Q Homlold.
<br />
<br />Q Acold.nlQ P.ndlng Inv..ligalion
<br />
<br />Q YES
<br />
<br />.4'NO
<br />
<br />Q Othor (Spocity)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />Q YES Q NO
<br />
<br />22.. DATE OF INJURY (Mo., D.y, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.AI horn., f.rm, stroot, f.Olory, ollice building, conslructlon sit., elc.(Spocily)
<br />m
<br />
<br />Q YES Q NO
<br />
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23.. DATE OF DEATH (Mo., Dsy, Yr.)
<br />\1-- l:> -o'l
<br />
<br />240. DATE SIGNED (Mo.. D.y, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />f'A.-O
<br />
<br />~~~
<br />iu~
<br />"tZ
<br />. [20
<br />1!is
<br />,2a:U
<br />all
<br />
<br />m
<br />
<br />23b. DATE SIGNED (Mo., D.y, Yr.)
<br />\1- \3-V~
<br />
<br />23d. To the b..1 01 my knowledg., de'lh occurr.d '1lhe time, d.t. .nd plac.
<br />.nd due to th. e .t. (Slgnalur. .nd TltI. ), '"
<br />
<br />23c. TIME OF DEATH
<br />',Ze:- a. m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />25. DIDT08ACCO USECONTRI8UTETOTHE DEATH? 26.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />__. Q YES ~?,~B,~~L~KNOWN Q YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type Or Print)
<br />Rebecca Steinke M.D. 2116 West Faidle Ave. Grand
<br />
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />.249. On the basis of examination and/or investigation. In my opinion death occurred at
<br />the tlm., dsl. .nd plao. snd du.lo the o.us.(s) stat.d. (Slgnalur. .nd TiU.) '"
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />NOI Appllcsble If 26.!, NO Q YES Q NO
<br />
<br />Island NE.
<br />
<br />68803
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />NOV l' 7 2008
<br />
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