Translation of possible death record Polish to English


I have submitted a document (address below) for translation, from Polish to English.  believe it is a death record, but I am not 100% sure. I also believe that this person, Sieywa, had at least three children. I am trying to collect documentation to verify.
    Whatever information can be gotten from this document would be appreciated.  Please respond to the form provided on ViewMate.  Thank you very much.

Matt Handelman