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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT O
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE l1
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY
<br />DATE OF ISSUANCE
<br />APR 0 9 2gtq 2 p 10 U 2 5 U~
<br />LINCOLN, NEBRASKA
<br />;4LTF,/,'Y~tIMYQ~I ERVICES, IT CERTIFIES
<br />A~r ~~~~~~~'•HEALTHAND
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<br />rST,A~ Ti4T~ R~~757 R.RR .'
<br />lR'~~ J~fIC7"H ,41~b ; _d
<br />AIV SERV,tCxES .' ~ • ,'
<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERV4~ES;~`,.,/~~?ty~ri:`.(3,~j''`7^(j;~.
<br />ERTIFICATE OFD 1 rJ C ` F O
<br />1. DECEDENTS-NAME (Flrat. Middle, Last, Surflx) 2 SEX ~. DA F'. TH (Mo.,Wry,Yr.)
<br />Leona Luella Bydalek Female March 30, 2010
<br />4. qTY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6i AGE-Coat Blwtday b0. UNDER 1 MBAR bc. UNDER 1 DAY 6.OATLr OF BIRTH (Mo., Day, Yr.)
<br />(Yn.) M08. DAYS HOURS MINE.
<br />Loup City, Nebraska 85 November 30, 1924
<br />7. SOCULL SECU WTV NUMBER 8a. PLACE OF DEATH
<br />508-3D~863 HOSPITAL: ®Inpeperit 4It)EB: ^ Nuislnq HaiwLTC ^ Hoaploe Faclllty
<br />86. FACILITY-NAME (Ir nol Inetlluddn, glue street and numWr) ^ EWQidpatleM ^ Deoedem'e Home
<br />Saint Francis Medical Center ^ oaA ^ om.r(sp.cdy)
<br />Ba. qTY OR TOWN OP DEATH (Include 27p Coda) 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />~ W. RE814ENCE.aTATB 86. COUNTY ga. CITY OR TOWN
<br />IL
<br />~, Nebraska Hall Grand Island
<br />9d. STREET AND NUMBER ie. APT. NO. 1K. PP CDDE Yg. INSIDE CITY LIMITS
<br />~ 1218 W. Division 68801 17 Yp ^ ~
<br />1Oe. MARITAL STATUS AT TIME OF DEATH ®Malrlad ^ Nawr Herded tOb. NAME OF SPOUSE (Fled, Middle, Last, Surflx) h wIN, qWe mr{tlen Hama.
<br />g ^ Martl°d, hilt a°perae.d p vnadrvad ^ Dirolcea ^ unNnown Ernest R 6ydalek
<br />~1" 11. FATHER'S-NAME (Pint, Middle, Last. $uRlx) 72. MOTHER'S-NAME (Fllal, Middle, Malden 8umama)
<br />Geo a Heil Alma Thom son
<br />~ 13. EYER IN U.$. ARMED FORCES? Giva dates or aeMu N Ya. 14e. INFORMANT-NAME 1Ab. RELATIONSHIP TO PECEDENt
<br />Imo- (Yea, No, drunk) ND Ernest R B dalek Husband
<br />16. METHOD OF DISPOSmON ae.:'E ~ MER~IGNATURE..y 184. L1CEN8E NO. 18c. DATE (Mo., Day, Yr.)
<br />®aend ©gaydnn ~~~„_ 1092 A ri15, 2010
<br />^Cnmaeon ^emomairm
<br />STATE
<br />^ ItMldval ^plMnapecxyj 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITYITOWN
<br />Westlawn Memorial Park Cemetery Grand I$land Nebraska
<br />17e. FUNERAL HOME NAME AND MAILING ADDRteBS (Street, City or Town, State) tom' 27p ~°
<br />Curran Funeral Chapel, 3005 S. LDCUSt 5t., Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam les)
<br />te. PMT 1. temw aM CINM d aedOF - dlwMr, Mfurinu, ar Camplicagonf-Mnr dllwYly f+4Md 1ha Mdh. n0 NOT Mlnr pmlllW ew11t~ wd1 a uNhc NMt~ .APPROXIMATE INTERVAL
<br />rsapiratory amft. w wmnGUNU eedil.don wmwrt.hoadna tlis atlaapy. lb Npt A89aEV1AtE. 6,rr only on. cww on a Nm. Ado eddxln,ul Iins x n.cssary.
<br />IMMEDATE CAUSE: omat to death
<br />IMMEDIATE CAUSE (Final
<br />dfeaaee or condiGao raaultlitg al / 9 4 ~ ~ ~ ~ ~ ~ ~'ti ~e ~~ y ~~ ~ J a
<br />In deegl)
<br />DUE TO, OR AS A CONSEQUENCE OF: : oitsn to ~~
<br />tMquudidly lief Cendltlena, M
<br />any, leading to the Cause listed b) C ~ ~ Jr'4 . 4 O ~ Y/ ~, s. f`~ Cr G
<br />on tln• a. DUE TO, OR AS A CONSEQUENCE OF: ~ olnn to daettt
<br />Enter the UNDERLYING CAUSE cl
<br />(direue or Injury that IMtlated
<br />the events nreultlnq in death) DUE TO, OR AS A CONSEQUENCE qF: ~ amst in deetlr
<br />LAST
<br />d)
<br />1& PART II.OTHER SIGNIFICANT CONpmONS-Conditfona con616utlllg to the death but not nwltlng in gls undarlylnq touts given In PART I. 18. WAB MF-DICAL EXAMINER
<br />OR CORONER CQNTACTED7
<br />^ YES ~ NO
<br />a
<br />W ZD. IF PEMAL!°: 21e. MANNER OF DEATH Ztb. IF TRANSPORTATION INJURY 27c. WAS AN AUTOPSY PERFORMED?
<br />LL ~Flot pregnene wltllin poet year ~Nawrel ^ Hamlcide ^ Drlvar/Oparator ^ YES
<br />F
<br />~ ^ Pnpnant at tlitw of death ^ Accident ^ Pending Irnptigatlon ^ Passenger 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />C1 ^ Not pregnant, but pregnant within 42 days of death ^ Sulcids ^ CauW not bs detemtined ^ Pedplrtan TO COMPLETE CAUSE OF DEATH?
<br />t~1 ^ Not ptagnardt nut pregnam 43 days to t year pefon death ^ air lt9p.~KY1 ^ YES ^ NO
<br />^ Unknown N pnrgnerN wtlhln the pen year
<br />a ,
<br />~ 22a. pATE DF INJURY (Mo., wy, Yr.) 22b. TIME OF INJURY 22c. PLACE pF INJURY-At home,lann, attaeR factory, ottica building, conrtructlon na, etc. ($pecily)
<br />O
<br />v m
<br />m
<br />m YYd. INJURY AT WORK? 22a. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />~ ©YES ^ NO
<br />22r. LOCATION 4F INJURY -STREET 6 NUMBER, APT. NO. CITY/TOWN STATE ZIP COOS .
<br />23a. PATE pF DEATH (Mo., Day, Yr.) Z 2Ae. DATE &GNED (Mo., Day, Yr.) Rob. TIME OF DEATH
<br />~~ ~Ck1 ~. 'Zb\b ~'~~ °1
<br />236. DATE $KSNED (Mo., Day, Yr.) 2Sc, TIME OF DEATH y O 2~c. PRONOUNCED DEAD (Ma., Day, Yr.) 2Ad. TIME PRONOUNCED DEAD
<br />K
<br />o°~ A ~\ Z• 1A\0 S:Zto m R i o m
<br />23d. To lha beet of my knowledge, death occurred et the bme, dab and place ~ ~ ~ 2es. On the beala of dxaminatlon andlor Invastlgatldn, in my apinbn daatli occurred
<br />F ~ and duo to the cauaa(s) afaled. (Slgrtawm end Title) ~ ~ Q7 at the tlme, data and place and due to the cauaa(a) tdahd. (Signatwa and Tills)
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<br />C~-G^Tt..P 2 •Q~°~-p ~ o
<br />2b. DID TOBACCO U$E CONTRIBUTE TO THE DEATH9 28.. HA8 ORGAN OR TISSUE DONATION BEEN CONSIDERED? 2tlb. WAS CONSENT GRANTED?
<br />[] YE$ ^ PRO6ABLY ^ UNKNOWN ^ YES NO Mae Appliee6le tl 2as i° NO ^ YES
<br />Tr. NAME, E AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSNIAN ASSISTANT, CORONER'S PttYSIC1AN OR COUNTY ATTORNEY) (Type or Pdnry
<br />Danltal Cronk M.D. 820 N. Alpha Grand Island, NE 68803
<br />28a. REGISTRAR'$ SIGNATURE 28b. DATE FILED BV REGISTRAR (Mo., Day, Yr.)
<br />P iL>!-Ir~r ~ ~ APR 7 2p10
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