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RD. COMP X ~ /~ .'r Z
ADAMS COUNTY NE
FILED
INST. N 0. `~.Q,~.$~ Q Q U
Date ~/9;0g Time ~'L':;~,,~1
~~
? N y~/,".7~ea ~e COMPARE / REGISTER OF DEEDS
hltsta~ ,~~ ~gto/ yyZy CADAS - 0 ~ -
-7"f7 ~ ~us~f o n ~ !~ ~ ~ d v~ec~ -~~i.~-~- y -F'~ r,~ s- C /s~~ -~~e~- off' lo-f ~v e C.S~
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WHEN THlS COPY CARR/ES THE RASED SEAL Of THE NEBRASKA STATE DEPARTMENT OF HEALTH,
? CERT/f/ES THE BELOW TO BE A TRUE COPY Of AN OR/G/NAL RECORD ON F/LE WITH THE STATE 2 Q Q ~ i Q 9 Q
DEPARTMENT OP HEALTH, BUREAU Of V?AL STAT/ST/CS, WH/CH IS THE LE_G_AL-DEEDS?-0RY fO/~-
V?AL RECORDS. j~,I
DATE Of /SSU E - ~ -' •~ " "'
OCT 16 1J~~j S~~4N EY S. COOPER
ASS/STSINT ~b4TE REG/STRAR
L/NCOLN, NEBRASKA NEBRASKA DEPARTMENT=OF:NEALZH
~ STATE OF NEBRASKA -DEPARTMENT OF HEALTH -=
- =_ --- -
BUREAU OF VITAL STATISTICS - --
Amended October 15 , 1996 ~ CERTIFICATE OF DEATH
1. DECEDENT -NAME FIRST MIDDLE LAST 2. SE% 3. DATE OF DEATH /MOnlh. Day. Year)
Dennis Eugene Pelowski Male September 23, 1996
4. CI7V AND STATE OF BIRTH 111 not rl USA.. name country/ Sa. AGE - Lasl Binhday UNDER t YEAR UNDEP 1 DAV 6. DATE OF BIRTH /MOnlri. Day. Year)
Greenfield Township, ND `YrSI 63 6b. MOS. I DAYS 6cHOURSI MIN3 June 10, 1933
7. SOCIA
L SECURTIV NU
~6
4i 8a. PLACE OF DEATH
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JO1-28 -}°D~J'Zr- HOSPITAL: ~ Inpatient - OTHER: ~ Nursing HOme
Bb. FACILITY -Name (ll no! inslifofion, give sheaf antl number/ ~ ER Outpatient ® Residence
I~ 817 N. Burlington ~ DOA ~ Olher/Specdyl
Bc. CITY. TOWN OR LOCATION OF DEATH 8d, INSIDE CITY LIMITS Be- COUNTY OF DEATH
Hastings Y
® N
~ Adams
ea
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9a. RESIDENCE -STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER /Inc/utlirg Zip Code/ 9e. INSIDE CITY LIMITS
Nebraska Adams Hastings 817 N. Burlington 68901. ^
Yea Nd
10. RACE - le.g., While. Black. American Indian. 11. ANCESTRY le.g.. Italian. Mexican, German, etc) 12. ®MARRIED ^ WIDOWED 13. NAME OF SPOUSE 111 wile. give maiden name/
elc.l lSOecity~ 7-yt..,lte
YY11 ISpeoih') pmeriean NEVER DIVORCED
M Marjorie Glover
14a. USUAL OCCUPATION /Give kind o/work done during most 14b. KIND OF BUSINESS INDUSTRY 75. EDUCATION (Specify only highest grade completed)
of working wen ilrelired/
~°ireman
City government EI lary or Secondary 10-12) College It-4 or 6~1
i"~"
16. FATHER-NAME FIRST MIDDLE - LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
John D. Pelowski Helen L. Werkus
16. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT-NAME
"yesr°nk~ Kc~~~anra~date~ylaegicps%8-30-55
J
l J 1 Marjorie Pelowski
19b. INFORMANT MAILING ADDRES
S
(STREET OR R.FD. NO., CITY OR TOWN, STATE. ZIP)
817 N. Burlington Hastings NE 68901
20. EMBALMER - SIGNATUPE 8 LICENSE NO. 11 D ~
~F- Q 21 a. METHOD OF DISPOSITION 21 D. DATE 21 c. CEMETERY OR CREMATORY ~ NAME
®Burial O Removal Sept 26, 1996 Parkview Cemetery
22a. NERAL H E - NA 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
Brand-Wilson Mortuary ~ Crematbn ^ Donation Hastings NE
22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
505 N Bellevue Hastings NE 68901
23. IMMEDIATE CAU IEN7ER ONLY ONE CAUSE PER LINE FOR lat. Ibl. AND Icll I Interval between onset and death
PAR
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~ DUE TO, OR AS A C/O-NSEOUENCE OF: ~ I Inlervafbelween onset and death
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DUE 70. OR AS A CONSEQUENCE OF: I Interval between onset and death
1 I
Icl I
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OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death bN not related
PART PART III IF FEMALE- WAS THERE A 24. AUTOPSY 26. WAS CASE REFERRED TO MEDICAL
II PREGNANCY IN THE PAST 3 MONTHS? E%AMINER OR CORONER?
(Ages 10-Sd) Yes No Yes No Ves No
26a. 26b. DATE OF INJURY (MO.. Day. n.J 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
Accident ~ Undetermined
M
Smcide ~ Pending 26e. INJURY A7 WORK 261. PUCE qF INJURY - At hom , term, sveel, factory
oAlce budding. eta /Speci/yf 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
^
Homicide Investigation ^ ^
Yes No
27a. DATE OF DEATH /MO.. Day Yc) 26a. DATE SIGNED IMO.. Day. Y</ 26D. TIME OF DEATH
~ a w M
6 J 27b. DATE SIGNED~7/MO.. Dtay. rl
~~ 27c. TIME OF DEATH ~ i ~ 2Bc. PRONOUNCED DEAD IMO. Day, riJ 2Bd. PRONOUNCED DEAD /Hour/
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~ 27d. 7o the best of my knowled e. death rred the ti e, dale and Dlace and due to.tl~e /
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causels) staled
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° e 26e. On the basis of examination and~or investigation, in my opinion death occurred at
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ISi nature and Title -~ Me lime, date and place and due to the causelsl stated.
Si nature and Title
29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
YES ~ NO'UNKNOWN ~ YES ~ NO ~ VES ~Q___
31. NAME
AND ADD S Ofi CERTIFIER )PHYSICIAN, CQ
RONER'S PHYSICIAN OR COUNTY ATTORNEY (Type w PrinlJ ,.~ -~..~_/ _.
I1
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/
~~
32a. REGISTRAR 32b. DATE FILED BY REGISTRAR /MO.. Day. YrJ
OCT 2 1996
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