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STATE OF NEBRASKA
<br />' ~ •,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA~ZY41~1~1471i4q~A11I.;,~E(ZVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBREJSI~A~.'l3EpARTMEMT OFD HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE WHICH IS THE LEGAL DEPOSITORY FOR'VI7:AL R~ ~ ,~ '•. `' '. `
<br />PATE OF ISSUANCE ~" ~~
<br />~~~ ~~ 2 010 0 0 4 9 5 ASSI'STAN~~TA'T~~ TRAM;, '.
<br />~P,y'~iTMENT OF`FIEJ4LTl-I~A,'N6~'
<br />LINCOLN, NEBRASKA MUM.41V1 S~f~ICES ' ' `, r i^ . •• ~"~ °''
<br />~ ~~ ....
<br />STATE OF NEEtRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND S7JI`dPDRT
<br />_ _ CERTIFICATE OF DEATH ~ • ~:~ ~ ~~
<br />.. ~ 1. DECEDENT'S•NAME (First, Middle, Last, ~ Sutfix) 2. SEX I 3. DATE DF DEATH (Mo., Dfly,Yr.)
<br />Leo Michael Wieczorek Male July 12, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Dey, Yr.)
<br />(Yrs.) MOS. DAYS HgURS MINS. ,
<br />M',a; h: Soelus , Nebraska '17 Jtuso 12 , 1932
<br />7. SOCIAL5EGURITVNUMBER Sa.PLACEOFDEATN
<br />~' 507-34-6185 )dOSPITAL: ^ Inparant 4IIiEf} ^ NuraingHomelLTC ^HoaplceFanikty
<br />Bb. FACILITV•NAME (It not Inentdlfon, give 6tr9et and number) ^ ER/Outpatiant 1g Oeoedent'a Homa
<br />'~ 503 W. Louise St ^ ter, ^Other(Speclty)
<br />P I -_
<br />9c. CITY OR TOWN OF DEATH (Include ZIp Code) M Bd. COUNTY OF DEATH
<br />Grand Island, 6$801 Tull
<br />Ba.RESIDENCES7ATE gb.000NTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island _
<br />gd. STREETANDNUMBER ge. APT. Np 9f. ZIP CppE Sg. INSIDE CITY LIMITS
<br />5O3 W. Louise St 6$$O1 ~ ~ YE5 ^ NO
<br />Fz 1 pa. MARITAL STATUS AT TIME OF DEATH[Married C7 Never Mewled tpb. NAME OF SPOUSE (First, Middle, Last, Sulflx) It wife, give maiden name.
<br />,. ^ Married, bulseperalatl ^ Widowed ^ Divorced C.1 Unknown LaDOnna Wilson-Van Ohlen
<br /> ~ ~
<br />~' 11. FATHER'S•NAME (Ebel, Middle, Laat, Sullix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />Michael Wieczorek Mary Hansen
<br /> 13. EVER IN U.5. ARMED FORCES? Glve dates of service If yes. 14a.INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br /> LaDonna Wieczorek Wife
<br />(Yes. nc, pr unk.) NO __
<br />~
<br /> t9b. LICENSE N0. 18c. DATE (Md., Day, Yr. )
<br />15. METHOD OF DISPOSITION tea. EMBALMER•SIGNATURE
<br /> '
<br />i ' pBurial ^ponallCn Not Embalmed Jn1 13, 2009
<br />_~. -_.
<br /> _. . __ ._.
<br />~Cremetlon ©Entom6ment 18d. CEMETERY, CREMATORY OR OTHER LOGATIpN C17Y /TOWN STATE
<br /> ^Ramaval ^Dther(spapuy) Central Nebr. Cremation Service Gibbon, ~
<br />' "' 17e.FUNERALHOMENAMEANDMAILINGADORESS (S1real,CityorTown,Stale) 3005 So. Locust St. ~ 174. Zip Code
<br /> '~•
<br />,_,;~ 68801
<br />Curran E~ineral Chapel Grand Island, NE
<br /> :~;,dr. ,. r ., ; . ,
<br /> 18 PART I. Enter the Gh1m pf r:YCDSfi diseases, injuries, orComplications--that directly Caused the deals, pp NOT enter terminal events such as cardiac arrest, ~ APPROXIMATE INTERVAL
<br />I
<br /> 'f ~~ s~~ respiratory arrest, pr ventricular fibrillation wltndut showing the dtiology. DO NOT ABBREVIATE. Enter only dna Cause on a line. Add addltlonal lines it necessary, I
<br />
<br />- I onset l0 death
<br />IMMEDIATE CAUSE:
<br />I
<br /> . /~~/ J~
<br />41fl~flr
<br />C~IeMol~~S pr~tor ~ I
<br /> '.: IMMEDIATECAl1SE(Flnal (~ ....._...
<br />dlaeaaear.wrrdltlan resledng DUE T0, OR A5 A CONSEQUENCE OF: ^~j /t I onset to death
<br />in death) mt tQy.f.,~ 114
<br />(p) ~np ~fac-,~ L Iq CJ011C~1~ - Colorectal
<br />Sequenitslly list conditions, If
<br />arry,leeding [o the aeuse tiered DUE TO, OR ASACONSEOUENCE pF:~~ _ I snail to death
<br />on Ilse a.
<br />ErdergtauNDERLYWGcAUSE
<br />(dlaeaaa or In)ury that inltlated (c)
<br />theeventareaultingindemh) ^pETO,ORASACONSEpuENCEOF:
<br />LAfiF
<br />xx,
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditlone contributing to the death but not resulting in the underlying cause given in PART I.
<br />,N_
<br />^ Mot pregnant, but pregnant 43 days tp t year before death
<br />[a Unknown If pregnant within the past year
<br />20. IF FEMALE: 2ta. MANNER OF DEATH
<br />^ Not pregnant within past year Natural ^ Hdmiclda
<br />Q Pregnant at lime of death ^ AccldantQ Pending Invastlgatlon
<br />^ Nol pregnant, but pregnant within 42 days of deals I ^ Suicide ^ CoukJ npl be determined
<br />3TIiFE ZIP CODE
<br />-~ 24a.DAT~SIONEQ (Mc.,pay,Yr.) 246.TIMEOFDE97H_ r
<br />~,+~= r ~ iii
<br />FR ~
<br />~ O lac. PRONOUNCED DEAp (Mo.. Dey, Vr.) 24d. TIME PRONOUNCED DEAD
<br />~Qa ~ m
<br />E¢~o
<br />s w x 24e. On the basis of exeminetlon and/or investlgatlon. in my npinlon death occurred at
<br />g ~ p the lima, date and place and due to the cause(s) stated. (Signature and Title) ~
<br />hpU
<br />U ~$
<br />25.DIDTOBACC USE CO RIBUTE HEM P 26a. HA5 ORGAN pR TISSUE DONATION BEEN CONSIDERED? 28b. WA$ CONSENT GRANTEp?
<br />^ YE5 ^ PROBABLY U UNKNOWN n YE5 __ ~ NO Nol Applicable if 26a i9 NO Q YES ~ NO
<br />~. _ _.-
<br />27. NAME, TITLE ANDADDRE550FCERTIFIER (PHYSICIAN,CORONER'5PHYSICIAN OR COUNTYAT!ORNEY) (Type or Print)
<br />Elpidionestor Iloreta 408 N. Howard Av Grand Island,NE 6$803
<br />28a. REGISTRAR'S SIGNATURE 296. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />~ ,~. '~ ~u~ x s zoos
<br />228. DATE OF INJURY 0. Day Vr) r22b TIME OF INJURY
<br />a .. 22d.INJURY AT WORK CSCRIBE HOW INJURY OCCp/pRED 99
<br />221. LOCATION OF INJUFlY -STREET 8 NUMBER, APT. N0.
<br />~• ~~23a. DATE OF DEATH (~ ,Dey, Y,_ r.) ~ ~ ~ ^l
<br />i 1 ~'r. I a~7+wWn
<br />~i +~. -1- ... - -
<br />' ~' _ ~ 236. DAT SIGN p (Mp., Dey, Yr.) 23c.T~$r0 ~TJr
<br />a ^/ ~Y~ m
<br />~~o
<br />23d. the beet m Owledge, death occurred at the time, date end place
<br />.~' nd due to th s s) slat (Signature and Title)
<br />Q
<br />
<br />22c PLACE OF INJURYA~thom~e,
<br />CRY/fpWN
<br />21 b. IF TRANSPORTATION
<br />^ DriverlOperator
<br />^ Peseenger
<br />I nnBHt to death
<br />I
<br />18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />^ YES ~ NO
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />^ YES ENO
<br />^Pedestrlan 21d.WEREAUTOPSYFINpINGSAVAILABLETp
<br />^Olher (SpeCifyl COMPLETE CAUSE OF DEATHS
<br />__ ~ ^YE5 ^ Np -
<br />n, street, lielary, ollice building, eanstruCtlpn site, etc. (Specify)
<br />=~~.~
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