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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEA
<br />SYSTEM, IT CERTfFIES THE BELOW TO BE A TRUE COPY OF THE.(TRIG�
<br />THE NEBRASKA HEALTHAND HUMAN SERVICES SYSTENT, VIT�t S`_TA7
<br />THE LEGAL DEPOS►TORY FOR VITAL RECORDS.
<br />DATE OF /SSUANCE _ '- �
<br />MAR 1 2 2007 =
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<br />L/NCOLN, NEBRASKA ' HE/�E
<br />2Q�.105145
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<br />STqTE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICE�u WI(VAN4�Ek�7iI.SUPP
<br />CERTIFICATE OF DEATH � 5� a
<br />1.DECEDENT'S.NAME (Firat, Mfddle, last, Suffix) 2.SEX 3.DATEOFDEATH(Mo.,Day,Yr.)
<br />Joseph Ephrem Ciemnoczolowski Male February 28, 2007
<br />4. CITY AND STA7E OH 7ERAITOAY, OR FOAEIQN COUNTRY OF BIHTH 5a. AOE-Lest Birthday 5b. UNDER i YEAR 6c. UNDER 1 DAY 8. DATE OF BIRTH (Mo.. Dey, Yr.)
<br />�'�.17A� Nebraska (Yre.) 86 MOS. DAYS HOUR3 MiNS. Jan.uary 22, Lg21
<br />7. SOCIAL SECURITY NUMBER
<br />506-50-9186
<br />8b. - FACH.-I�Y-ddl�iv1�- -{-}#- nob dnsY#t�tJeu, �$lus-�
<br />Wedgewood Care Center
<br />. PLACE OP DEATH
<br />HOSPITAl ❑ �npaliant 9I1� �I NureingHome/LTC ❑HoaplceFacility.
<br />- � - - EW(lntpatlegt "0 ----- -
<br />❑ 001 � . Q OTher (3pecHYj
<br />Ba CITY ORTOWN OF DEATH Qnclude Zip Code) 8d. C0UN7'Y OF DEATH
<br />Grand Island 68803 Hall
<br />9g. IN3IDE CITY IIMfTS
<br />❑ YE3 �1 NO
<br />11. FATHER S-NAME (Firet, • Middle, Laet, Suffix) 12. MOTHER'9•NAME (Ftrst, Mfddle, Maiden SurnameJ
<br />Ignace Ciemnoczolowski Apolina Marsha.lek
<br />13. EVBFi IN U.S. AAMED FORCES? (iNa dates of service It yes. 14a. INFORMNNT-NAME •' 14b. RELATIONSHIP TO DECEDENT
<br />nes ,no,arank.) NO Nancy Ciemnoczolowski Wife
<br />15. METHOD OF DISPOSRION i6e. EM9ALMER-SIQNATURE t6b, LICENSE N0. 1 Bc. DATE (Mo., Dsy, Yr. )
<br />CgBurlal ❑Donailon � -/� �/�3.�.5� March 5 � 2���
<br />❑ Crematton ❑ Entombmenl 16d. CEMETERY, CREMATORY OR HER LOCATION CITY/TOWN 37ATE
<br />❑Removel ❑Olher(Speeltyj Westlawn Memorial Park Cemetery Grand Island, NE
<br />fla FUNERAL HOME NAMEAND MAILINQ ADDHESS (Straet, Gity orTown, State) 17b. Zip Code
<br />Apfel Fun.eral Fiome, I123 West 5econd, Grand Island, NE. 68801
<br />Ba. RESIDENCESTATE 9h CAUNTY 8c. CI7Y ORTOWN
<br />Nebraska Hall Wood River
<br />9d.5TREE7AND NUMBER 9e. APT. N0 8t. ZIP CODE
<br />783 S. 130th Rd. 68883
<br />10a. MARITAL STATUS AT T(ME OF bEATH � Merrled ❑ Never Marrted 10b. NRME OF 9P0l13E (Flrat, A9lddle, last SIl�tflX� If WIIB, glve meiden name.
<br />❑ Married, but seperated ❑ Widowed ❑ Dfvorced ❑ Unknown Nancy Bachkor�
<br />1& PART L Enter the ohein ot eaente••dtseaeas, frtjuries, or campllcatiorts-that directly causad fha deatFi, DO NOT enter terminal evente euch ae cardiac errest, � APPROXIMATE INTERVAL
<br />i
<br />respiratory arreai, or veniricuiat fibrillailon wfthout showing the etiotogy. �0 NOT ABBREVIATE, Enter only one cauae on a Iina Add addlHone� Ilnes H nscessary. �
<br />IMMEDIATECAUSE: i onaettodeath
<br />m�rnmrnrECnusec� � 1�F'SQ��-Y1.t�.��y ��U�l�e, (���., � �Ne49V���Ki�C,� "1!� �° 'Zusl�-S
<br />diaeaeeorcorxiitlonresulNr�g DUETO,ORASACONSE�UENCEOF. I onsettodeath
<br />tn daetfi) x �
<br />SequeMlaltyllatcondltlone,H N) ���e..� ��,'.. ��� � �� � �,�.�
<br />azry, Ieeding ta thecause Ils[ed DUE T0, OR AS A CONSEQUENCE OF. I onset to death
<br />on tlne a.
<br />FrderUreUNDEHLYIN�CAUSE I
<br />(diseaeeorin)uryihetinldated � ' I
<br />i
<br />the eveMereaWHng b de�h� DUE TO, OR A9 A CONSEQUENCE OF: � � Onaet to death �
<br />11�ST
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<br />18. PART II.OTHEfl SIONIFICANT CO OITtONS•ConB conidbuting M the deatfi but rt t rasulting o the urtdariying cau e glven )n P�R I�. 19. WAS MEDICAL EXAMINER
<br />� S �J� � C�-� � �'„ �,'�' �. Y�'�C6'��. � (ib�.�n� �k � V �� �15�� �� C�" v""� � OR CORONER CONTACTED7
<br />❑ YES �"NO
<br />20.IFFEMALE: ' 21a.MANNEROFDFATH 216.IFTRANSPORTATIONINJURY 21c.WA5ANAUTOPSYPERFORMED?
<br />❑ Not pregnant wilhin past year �lemral ❑ HoMelde 0 Oriver/Operaror .
<br />❑ Pregnent at time of deaih ❑ Accident0 Pertdtng InveallgaUon
<br />❑Paeaenger ❑ YES �NO
<br />CI Not pregnant, bui pregnant wltidn 42 daye of deatfi � pad ��� 21d. WERE qUTOPSY FlNDINQS AVAILABLE TO
<br />❑ Sutolde ❑ Could hat be determined � Other (Specl(y)
<br />C7 Notpregnant,buipregnent43deyatolyear6eforedeath COMPLETECAUSEOFDFATHI
<br />❑Unknovmltpregnantwithinthepeatyear ❑ YE3 ❑NO
<br />22a. DA7E OF INJURY (Mo., Day, Yr.) 22b. TIME OF_INJl7RY 22c. PLACE OF INJURY•At home, ferm, etreet, factory, ofltca 6utfdfng, constructton sfte, eta (SpecHy)
<br />m - ,_
<br />22d.IMJURYATWOAK7 22e.DESCAIBEHOWINJUAYOCCURREb
<br />❑ YES ❑ NO
<br />22(. LOCRTtON OF INJURY- STREET & NUMBER, APT. NO. CfIY/fDWN 5DUE 21P CODE
<br />23a. DATE OF DEATH (Mo., pey, Yr.) � 24a. DATE 810NED (Mo., Dey, Yr.) 24b.TIME OF DEATH
<br />.�' � - c..�-"�°'' �, � IYI
<br />_} 23b. DATE SI6NBD (Mo., Day, Yr.) 23c.TIME OF DEATH ��� r 24c. PRONOUNCED DEAD (Ma., Dey; Yr.) 24d. TIME PAONOUNGED pEAD
<br />�o � ..., '�,,.-(D"'t � ,. fp E W < a nl
<br />�` 23d. To the best of my knowiedge, death oxurr et the time, date end place $ u� �� 24e. On the basis oi exeminetlon end/or invesNgation, in my opinion death oocuaed at
<br />a and due to Uaeeeuae ted (Slgneiur and Titie j� .� �$ the tlme, date and place and due to lhe ceuse(s) atated. (Signature and Titie ) r
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<br />25.OWTOBACCOUSECOAITRIBUTETOTF(EDEATH? 28a.HA50RQANOFTI9SUEDOMATIONBEENCONSIDEAED7 26b.WA3CONSENTORANTED4
<br />YES ❑ NO ❑ PHOBABLY ❑ UNKNOWN Q YE& NO Not Applicable If 26a la NO ❑ YE8 [�NO
<br />27.NAME,TITLEANDADDRESSOFCERTIFIER (PHYSICIAN,CORQNER'SPHY6ICIAN.ORCOUNTYATTORNEI� (TypeorPdnt) �
<br />Steven Husen M.D. 2116 W. Faidley Ave. ��400, Grand Island, NE 68803
<br />28a. REOISTRAR'S SI�NATURE �* 28b. DATE Ft1ED BY REOlSTRAR (Mo., �ay, Yr.)
<br />,��d�c � l,M�i, � MAf� ~ � ZOQ�
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