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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />` ~ THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD pN FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL ~GO~Q,~~,~ ;
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<br />DATE OF ISSUANCE ,~~/~~a~`":~) ~. ,H
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<br />IY~FiY ~. ~ ~~0~ ASSIS'1~if~IT STATE REG7.~7RAR ~ r
<br />2 0 0 9 0 4 2 g o DERA~T~?ENT t7~F1EALTH ~~~
<br />LINCOLN, NEBRASKA HUM~l7V..5~R+~C?ES r +
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<br />STATE OFNEBRASKA - DEPARTMENT OF HEALTW ANP HUMAN SERVICES FINANCE A~Ip 9hJgPOR~' , .. ~ rt
<br />CERTIFICATE OF DEATH ~f r ~~'Q:~ ~•~~~,',
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<br /> 1. DECEDENT'S•NAME (First, Middle, Last, Sulflx) 2. SEX ~ ~, ~ ~,~~;O~A7~1.,(kKv.,i]wy;vtlr.)
<br /> Annette NMI Kraning Female ~v, °,~~;~® .2p09.
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 59. AGE-Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. bATE OF BIRTH (Mo., Day, Yc) '
<br /> (rre.) 84 Mos. Drays HouRS MINS. November 16, 1924
<br /> Ashton, Nebraska
<br /> 7, 90CIAL SECURITY NUMBER ea. PLACE OF DEATH
<br /> 507-24-4253 HOSPITAL: ^Inpetlent 411d~J3 ~1NursingHome/L7C ^HosplceFaclllty
<br /> 8D. 1~ACILfliWN1~~'(If nel Inratltutlori, 91re atrir{C giid dumb'A1~" ' ' ~ '" "
<br />^ Eq/0utpatlant ~ bacadant'a Home
<br /> Wedgewood Care Center ^ Dx ^ other(speciry)
<br /> Bc. CITY URTOWN OF DEATH pnclude Zip Code) ~ 8d. COUNTY OF DEATH
<br /> Grand Island 68803 Ha11
<br /> 9a. RESIDENCE-STATE 9b. CgUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> 9d. STREETANONUMBER 9e. APT. NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 1127 South Lincoln St. 6$801 Y ~7 YES ^ NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ^ Mauled ^ Never Merrietl 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name.
<br />~,v- -. ^ Mauled, but separated QWldowed ^ Divorced ^ Unknown
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<br />~~ 11, FATHER'5•NAME (First, - Middle, Last, Suffix) 12. MOTHER'S-NAME (FIrs6 Mlddle, Malden Surname)
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<br />Slobaszewski
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<br /> Edward Ziola ne
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<br />'~' ARMEDFORCES?Glvedatesolservlceltyes.
<br />EVER INU
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<br />13 14a.INFORMANT•NAME 14b.RELATIpNSHIP70DECEDENT
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<br />(rea,no,orunk.) No Glen Lorance Son In Law
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<br />'~ 75.METHObOFDI5PO51TI0N
<br />QBUrlel ^Donelion 1lia.E BALMER•SIO ATU E ttih.LICENSENO. ilic.DATE (Mc.;Oay,Yr.)
<br />~~ ~ ~~ 138 MAST 14, 2009
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<br />i _wl, ^Cremation ^Enlombmenl ER LOCATION CITY !TOWN STATE
<br />16d.CEME RV, CREMATOR
<br />s., ORemoval ^Other(Specny) WeSt~awn Memorial Park Cemetery Grand Island, Nebraska
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<br /> 17b. ZIp Code
<br />1Ta. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or7own, Stele)
<br /> Apfel Funeral- Home 1123 West Second, Grand Island, NE. 68801
<br />s t13. PART I Enter the cheln of events••diseases, injuries, or oomplications•dhal directly Caused the death. b0 N07 enter terminal events such as cardiao arrest, APPROXIMATE INTERVAL
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<br /> respiratory arrest, Or venirlouler tlbrlllation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilse. Add additional lines if nedea9ary. I
<br /> IMMEDIATE CAUSE: I onset to death
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<br />IMMEb1ATB CAUSE (Final (a) ~~ W v„_....- ....- 1_...~ ~r~
<br /> dl9eeeeorcondlWnrewtung DUE TO, ORASACONSEOUENCEDF. I onseuodeath
<br /> in death) I
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<br />Sequentially list crondldone, Il 1b) -_
<br /> any, Ieadingtnthecaueelleted buE 70, OR A5 A CDNSEquENCE OF: I onset to death
<br /> on Ilne a. I
<br /> EnterthaUNPERLYINGCAUSE I
<br /> (dleeaeearln)urythatlnldaNd (c) ___ _
<br /> the evant9 rwuhing to death) DUE TD, DR ASACONSEOUBNCE DF: I onset to death
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<br /> 19. WAS MEDICAL EXAMINER
<br />1 B. PART IL OTHER SIGNIFICANT CONbI710N5-Conditions Contributing to the death dut net resulting in the underlying Cause given In PART L
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<br />OR CORONER CONTACTED?
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<br />20. IF FF~+IALE: 21 .MANNE EA7H 21 h. IF TRANSPORTATION INJURY 21c.WAS AN AUTOPSY PERFORMEb7
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<br />~'f ural ^ Homicide
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<br />01 pregnant wilnin past year [~ YES ~ NO
<br /> ^ Pregnant et time of death ^ Accldent^ Pending Investlgatlan ^ Passenger
<br /> ^ Not pregnant, but pregnant within 42 days of death ^ Pedestrian pis. WERE AUTOPSY FINDINGS AVAILABLE TD
<br />^ Sulclde ^ Could net be determined
<br /> ^'NOt pregnant, but pregnant 43 days to 1 year before death ^ Other (Specify) COMPLETE CAUSE DF DEATH?
<br />- ^ Unknown If pregnant within the pe51 year ••` ^ YES ~ NO
<br />^~ - ( y F INJURY•At home, farm, 91re6t, IdC(dry, OitiCa building, CdnSlruCilon site, etc. (specify)
<br />' 22a. DATE OF INJURY Mo., Da , Yr.) 22b. TIME OF INJURI~ plc. PLACE 0
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<br />~.. 22d.INJURY AT WORK4 22e. DESCRIBE HOW INJURY OCCURRED
<br /> ^ YES ^ NO ~
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<br />22f. LOCATION OFINJURY-STREET B,NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br /> y,Yr.) = 24a.DATESIGNEb (Mtl.,Day,Vr.) 246.TIMEOFDEATH
<br />23a.bA7E0FDEATH (Mo.,Da
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<br />s 23b. DA SIGNF~D~o.. Day, YL) 23FTIME~ EA7H ~~~ 24c. PRONOUNCED DEAD (MO., pay.Yr.) 24d. TIME PRONOUNCED DEAb
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<br /> ~ c ~ 24e. On the basis of examinetlonand/or investigation, in my opinion death occurred at
<br />23d.To the best of my knowledge, death occurred at the ume, date and place w ~
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<br />$ end a to the cause 1 state Signature and TIt g ~ the time, date end place end due to the cause(s) stated. (Signature and Tine)
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<br /> 25.DIDTOBACCpUSECONTRIBUTETOTHEDEATH7 26e.HASORGANORTISSUEDDNATIDNeEENCONSIDEREp? 266.WASCONSENTGRANTE07
<br /> ^ YES ~ Q PRDBABLY V UNKNOWN ^ YES ~,Olb_ Nol Applloable If 28a is NO ^ YES Ly~cO
<br /> 27. NAME, TITLE ANp ADpRESB OF CERTIFIER (PHYSICIAN, GDRDNER'3 PHYSICIAN OR COUNTY ATTORNEY) (Type ar Print)
<br /> Kimberly Michels M.A. 729 N. Custer Ave. Grand Island, Nebraska 68803
<br /> 28a, REGISTRAR'S SIGNATURE ` 28b. DATE FILED 8Y REGISTRAR (MO., Day, Yr.)
<br /> /~,,r'~/",., MAY 1 3 20Q9
<br />HHS-61 11/03 (55061)
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