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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEFIG~G~ AI~',HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE,wBF~S E A, , • ANT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY~'O~~ •,~~ ~ ,. .~
<br />~. M
<br />DATE OF ISSUANCE ~ "~~
<br />~_
<br />~ rANt,~'S' , ~rOOPER -,
<br />AUG ]. 4 2009 2 0 0 91014 2 - w~'SS~~~REfST~L4R
<br />~P Gt EAL;?1''!'.41~'ID
<br />LINCOLN, NEBRASKA ~~GG~M~~/w~y~~r~~"~y,~ r ~.r ,
<br />SLATE OF NE9RASlCA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCi A D S~~J ,;~ ~;~ 9 [~
<br />_ _ CERTIFICATE OF DEATH ~' - '~ r U J V _.
<br />1. DECEDENT'S•NAME (Eifel, _ Middle, Laet, Suffix) 2. SEX ~' 3.,DATEpFbEATH(MO.,Day,Yr.)
<br />Lois _ J• Zalewski Female August 7, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Lael Blrihday 5b. UNDER 1 YEAR 5C. UNDER 1 DAY B. DATE OF BIRTH (MO., Day, Vr.)
<br />(vra.73 MOS. DAYS HOURS MINS. January 30, 1936
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />506-40-1714 HOSPITAL ^ Inpatient 94JEB ~ Nureing HvmelLTC ^Hpspice Facility
<br />Bb. FACILITY•NAME (II not institution, give street and numbef) ^ ER/Outpatient Q Decedent's Home
<br />Tiffany Square Care Center ^ ern ^otner(speclry)
<br />8c. CITY OR TOWN OF DEATH (Include Zlp Code) Bd. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE-STATE ~ 9b.000N1Y 9c. CITY OR TOWN
<br />Nebraska Ha11 Grand Island
<br />°~ ~ 9e. APT. N0 9t. TIP CODE 9g. INSIDE CITY LIMITS
<br />f~ ", 9d. STREETANDNUMBER
<br />404 Woodland Drive 6$801 ~ Yes ^ ND
<br />tea. MARITAL STATUS AT TIME OF bEATH I~ Married ^ Never Marfisd 10b. NAME OF SPOUSE (Final, Middle. Last, Sulf1X) It wife, give maiden name.
<br />_~ ~. ^ Married, but separated ^ Widowed ^ Dlvaced ^ Unknown Gerald Zalewski
<br />.-, ~° 11, FA7HER'S•NAME (Final, Middle, Lest, Sulflx)T 12. MD7HER'S•NAME (First, Middle, Malden surname)
<br />Wesley T. _White _ Kathr n C. __Srown
<br />''' - •°~ 146. RELATIONSHIP TD DECEDENT
<br />' ~ ~ ~ 13. EVER IN U. S. ARMED FORCE37 GiVO dates of aervloe II yes. 14a. INFORMANT-NAME
<br />~'w~. (Yes, no, or unk,) No _ _ __ Gerald Zalewski Husband
<br />.F r r..~' 15. METHOD OF DISPOSITION i8a. EM LMER-SIGNA7Ug[ ,-~~ , 186. LICENSE NO. i 8c. DATE (Mo., Day, Yr. )
<br />•~;.F!~. y~purlal QDpnalion ~' L~f-Jr,y' 2~t3~S Y..17 AU ll$t L0, 2009
<br />16d. CEMETERY, EMATgRY OR OTH LDCATION CITY /TOWN STATE
<br />^ Cremation ^ Entombment
<br />^Rempval ^Other(5pecity) St. Marys s Catholic Cemetery Wood River, Nebraska
<br />• ..
<br />~,~ j. 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clly pr Town, State) 176. Zip Coda
<br />Apfe1 Funeral Home, 1123 West Second, Grand IsJ.and, Nebraska 68801
<br />18. PART I Enter the Chain of eventa••dlseaaee, injuries, Or Complications--that directly Caused the death, DO NOT enter terminal events such as cardiac erfesl, APPRpXIMATE INTERVAL
<br />~a~
<br />- resplfatory arrest, Of ventrlCUlar fi6rillalion without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause on a Ilse. Add additional Imes if necessary. I
<br />I Onsal t0 death
<br />IMMEDIATE CAUSE: ~y ~ ~/y I
<br />IMMEDIATE CAUSE (Final (a) ' ~"~~~~~`v~ ~ -- I ~ ' ~ ~~
<br />dlaeeeeorcOndltlpnresulUng pUE T0, OROR AS~~UENCE pR ~J I onset tC death
<br />I
<br />In death)
<br />~,~: : , I
<br />SaquaMlslly list condltlpns, ll lb) _ _. I -,.
<br />any,leadingtpthecaueentsled ~~-DUETD,ORASACONSEquENCEOF; I vnaettpdeath
<br />_ on tins a.
<br />EnkrthauNDERLYINGCAOSE I
<br />(dtaeaaeorln)urythat initiated 1c) -., _ _. I
<br />thaeventersaultinglndedth) DUE TD, ORASACONSEgUENCEOF: I Cnsettodeath
<br />1A5~
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<br />1S. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions cOntrl6uting td the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />~~ ~~y~ ~ ~'~r, v ~-• OR CORONER CONTACTED?
<br />~, ',-, 1 ` L,.+~J~ ^ YES ~ NO
<br />p 20. IF FEMALE:m ~ 21a. MANNER OF DEATH ~' 21 b. IF TRANSPDRTA710NINJURY 21c. WA5 AN AUTOPSY PERFpRMED?
<br />w ^ Driver/D orator
<br />Not pregnant within pest year Natural ^ Homicide P
<br />C]Paeaenger ^ YES ~I NO
<br />1~, ^ Pregnant at time pf tleath ^ Accident^ Pending Investlgadvn .,- ..
<br />^Petle6trlan 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />~~ ^ Not pregnant, but pregnant within 42 days of death ^ Suicide ^ Could not be determined
<br />^ Ndt pregnant, but pregnant 43 days td 1 yeer before death ^ Other (Specify) CDMPLE7E CAUSE OF DEATH7
<br />Unknown ll pregnant within ins past year ,,,,,~ ^YE5 ^ NO
<br />• 22a. DATE OF INJURY (Mo., Pay, Vr.) 226. TIME OF INJURY 22c. PLACE OF INJURY-At home, term, sireat, laClory, office building, conslruCtlOn site, etc. (SpeClly)
<br />~_m . _.. .- ._. _.
<br />22d. INJURY AT WDRKv 22e. DESCRIBE HOW INJURY OCCURRED
<br />- ^VES ^ ND _., .. ... .._ ...
<br />22f.LDCATION OFINJURY-STREET&NUMBER, APT.NO. CITYROWN STME ZIP CODE
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<br /> 23a. DATE OF DEATH (MO., Day, Yc) Z W 24a. DATE SIGNED (MO., Day. Yc) 2A6.TIME OF UkAI H
<br />m
<br />= C
<br />rn 236, DATE SIGNED (MC. Day,Yr.) 23C.TIMEOF DEATH ~~~~ 24c.PRONOUNCED DEAD (MO., Day, Yc) 24d.TIMEPRONOUNCED DEAD
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<br />~ 23d. Tp the beat of my knowledge, death occurred at the time, date and piece
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<br />occurre
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<br />24e. On the basis pt exeminetion andlor investigation, in my opin
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<br />~ ~ ~ the time, dale and place and due tp the Cause(s) Slated, (Signature and Title)
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<br />F and du t the cause(s) slat gna
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<br />25.OID70BA000 USE CONTRIBUTETO7HE DEATH? 28s. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREOP 266. WAS CONSENT GRANTED?
<br />^ YES NO ^ PRbBABLY ^ UNKNOWN ^VES NO Not Applicable it 28a is NO ^YE5 L:l NO
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<br />27. NAME, TITLE ANDAODRE550FCERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (TypedtPflnQ
<br />Anne Manse M.D. 729 N. Custer Ave. Crand Island NE 68803
<br />28a.REGISTRARBSIGNATURE
<br />.L~Jt,.
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<br />(. 2B6.DATEFILEDSYREGISTRAR (Mv.,Dey,Yr.)
<br />AuG ~ 2 zoas
<br />HHS•61 11!03 (55061)
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