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STATE OF NEBRASKA
<br />A �,�°� � .� , .
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HF�IL�F7 IR(d��/P��1 IT CERTIFIES
<br />_ THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE lVEBR,4$l�Ai�EQ,�Il�TM,�NT�"C)F �I,�AtTH A111D
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOi�I/l�i� ��1�� `,�`' ''� Y�
<br />�.. : ` .� ,/� , s
<br />DATE OF ISSUANCE '"` ° . ��1. `� �� °� ,
<br />, �,
<br />��� Q � t���� .�.S�i� ��PE �FSTRAR ,
<br />2 0 � 10 3� 6 4 D�P,�T`�M�NT OF HEALTH �4I1fD-, ��
<br />LINCOLAI, NEBRASKA HUMAN_S�9��t�5 �,C";`':•° t
<br />: � _' �_ � d.:� 1=� $ , ` .'` ._
<br />� STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIGES � `�' � ' r � v I � � ,' � � �i - �i G:
<br />' CERTIFICA E OF DEATH ° "`''' `' �"""
<br />1. DECEDENT'SNAAAE 1Fl�at. AGddle. L.aet 8uR4) . 2 8EX � 3. DATE OP DEATH'lm0.�riYr.)
<br />Benjaman Czaplewskl Male March 20, 2011
<br />4. GTY AND STATE OR TERWTORY, OR FOREION f�UUNTRY OF BIRTH Ba. AtiE-Lrt Birtluler 8b. UNDER 1 YEAR Ba. UNDER 7 DAY & DATE OF BIRTH (AAo, �ay, YrJ
<br />(YrsJ AAOS. DA1fS HOU� !AW&
<br />Loup City, Nebraska 87 June 29, 1923
<br />7. SOCIAL SECURITY NU6lBER . Ba� PLACE OF DEA7H - �
<br />0 50&1 &7610 H08PRAL: � InpaUm�t oTM�: � Nu�sl� HareILTC �'Hoapiee Faditty
<br />� �. �nciu�n-Nae�e �n ��nnm�,, �ve s�ee ana n�� ❑ Ewa�aueM ❑ o��ae�re Ho�
<br />� Tiffany Square Care Center � D° '� �°"'��'�
<br />c
<br />� 8c. CITY OR TOWN OF DEATH (InWuda Dp Code) 8d. COUNTY OF DEATN
<br />W Grand Island 88803 Hall
<br />Z �a. RESIDENCE�BTATE ' 9b. COUNTY ea CI7Y OR TOWN
<br />�
<br />LL
<br />3, Nebraska Hall Grend Island
<br />�p 9d. STREET AND NUAABER 9e. APT. NO. 9!. LP CODE 8g. a18iDE CrtY LIAS1Ii5
<br />� 204 E.19th 6$801 � r� ❑ No
<br />� tor. xaarra� srarus ar mu� oF o�►n�
<br />p x�aa ❑ Never Merrled 10b. NAAAE OF SPOUSH (Ftrst, lltddle� �, s�� e wxa s� mma� �.
<br />❑ ��' bB ` � � � ❑ D1io "�`' ❑ �" 1O1O7N " Muritta Borowiak
<br />°' ��. Fart+�re�sNaeee (�, ee+am�, tase. s�� �2 xorHeasauaeee ��, ee�ame, eemaan s�unarr»�
<br />E
<br />0
<br />� Ben Cza lewski Angeline Mend k
<br />0 74b. RELATIQNS}qP TO DECEOENT
<br />m 13. EVER IN U.& ARAAED FORCE89 Oive dafas of serviee HYea. 74a. a1FORAAIWT-NAINE
<br />O
<br />� rea Na oro�.) Yes 11/18/1942-10 Muritta Czaplewskf Wife
<br />1& b1ETHOD OF D�POSPiION �6� ERSIONATURE 78b. LICENSE N0. 18c. DATE (AAo., Day, Yr.)
<br />�� 0���� 1092 March 24, 2011
<br />❑�� �� �
<br />❑n�w pam�sn�ur► +ea. cae�r, c�taxaro oe on�at �moN crrrROwN � sraTe
<br />Grand istand Cily Cemetery Grand Isiand Nebreska
<br />17a FUNERAL HOM6 W1lA8 AND MAILINO ADORESS (S'treet, CHy m Town, 8ffite) ��• �P �
<br />CuRan Funeral Chapei, 3005 S. Locust S't., Grand Island, Nebraska 6880.1
<br />CAUSE OF DEATH (See instructions and examples
<br />1& PART L EMar W dmin o/eva� -�� �N��0. a'eomW��+s-tlmt tlimelly emtead 1M deaM. DO NOT mroertend�ml ew� auch aa mNfae ertest, ; APPROxIMATE INTERVAL
<br />��P�7 enast. �v�bia�arllG�adon rOhaR showNg ffie efiu�Wf. NOT ABBRBYIATE EMer oN1 wm ause m a Wm. AGtl ad�dmel �nae 0�r.
<br />1lAAAm : 011aet to deedl
<br />@IMEDIATE CAUSE ((r7nel `�
<br />d� w caMiElon �eau18� a)
<br />In death)
<br />DUE TO, OR AS NBEQUENCE OF: deafh
<br />Sequentla�ly qst w�limre. B b1
<br />a�tl� leading to ttre eause Iieted
<br />� p � B ' �� DUE TO, OR /l8 A CONSEQUENCE OF: � a� to deatit
<br />F��LartheUNDERLYIN6CAU8E �)
<br />(� ��� ��� DUE T0, OR AS A CONSEQUENCE OF: 7 oriset lo deafh
<br />tlre everRa reauifing In death)
<br />L.ABT
<br />d)
<br />1& P LL OTHER SfGMFICANT CONDITION&ComllBmie wntrl6uting to 1ha deaW h�R rrot reautting In ttre u�WeAyl� eeuee gtven In PART L 1& WAS AAEDICd1L EX/W WER
<br />/► � �� OR CORONER CONTA�TE�?
<br />l%i'(/� '�'�-�. ❑ � L{J�°o
<br />�
<br />W �• � ' 21a NER OF DEATN 21b. IF 7RANSPORTATION INJURY 27a WAS AN AUTO P RAAED?
<br />F Cl►� ��� a� r«► �❑►►o�dda. ❑ nm�no�m► ❑ rES Lct�
<br />v p�r�emrema�rn ❑ n�aa�e ❑ r�9 ��a� ❑ r�s�.
<br />� Not pregnmM, but pregnent witlUn 42 daya of death ❑ SWcide ❑ CoWd irot he detemdrted 27d. WERE AUTOP81f� AVAILABLE
<br />� ❑ Pedeatrlan TO CONPLETB CAUB F DFATH9
<br />pntoe �, w,e Pr�e aa m m��. mro� a� ❑ on�r(sa�rcr) p res
<br />,� CIU�known H piegnmit wifhin We �mst year
<br />m •
<br />G.
<br />E� 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIFAE OF INJURY 22c. PLACE OF WJURY-At home, tartn, street, tactory. oftice 6uit�ng, eo�Luctlon dte, etc. (Speci(y)
<br />v eq m
<br />Q 2Zd INJURY AT YYORK7 2Ta DESCPoBE HOYV INJURY OCCURRED
<br />�' ❑ YE8 ❑ NO
<br />YX. LOCATIOPI.OF INJURY - 8TRE6T & NUMBER, APT. NO. CRY/�OWRf BTATE aP CQOE
<br />� xie. U TE OF DFATH (dla. DeY, Y►) 24a DATE SIflNm (A1o„ DaY, Y►.) 24b. TId1E OF �EATH
<br />3!,� r 20 � 2011 ,ao �� m
<br />��' oa'rE cin�� (eeo, oay Yr.) T3c. TItlE OF DEATH �� 0 24e, pRONOUNCED DEAD (Alo., Day, Yr.) 24d. TiMH PRONOUNCED DEAD
<br />�� o rC 24r 2011 23:55 Pm Eq�<o m
<br />23d To of rtry laio�xl death oceurrad e! tlre tlme. dete mM place ��� 24e. On tlre bas� of e:m�dnadon ertd/m imreadgadoe. in my o�don demh aceimed
<br />�� me aa��e� lstenedue and'rttte) o� o ae are nme, dam a� p�ca mw aue to ede cau�s) amead. (stg�rewre m�a Tina)
<br />\ � ~ $`o
<br />xs. rnn se conirweurE oearx•r aea. eas oac�uw oR �sue now ema con�sw�oa 2s�. was coNSFxr awwreoa
<br />❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO NotApplicabte B26a is NO ❑ YE8 NO
<br />27. NAINE, 717LE AND ADDRESS OF CERTff1ER (PHYSICIAN, RHYSICIpN AS313TAN7, CpRONER'g pF1Y811CU1N OR COUNiY ATTORNEI� (Type or print)
<br />� John A. Wagoner Jr. M.D. S00 N. Alpha St Grand Island, Nebraska 68803
<br />28a REOISTRAR'3 SIONATURE 28b. DATE FILED BY REOISTRAR (ASo„, Day, Yr.y
<br />p � � ` MAR � A 2011
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