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STATE OF NEBRASKA �- � : ; ' : �
<br />WHEN TH/S COPY CARR/ES THE fL4/SED SEAL OFTHE NEBRASKA HEA��7f ���i9}►t,,��/�E8 _°�
<br />���'"ri,�'M, IT CERTIF/ES TH� BELOW TO BE A TRUE COPY OF THE G1RLGl�ht,4C �1`�D Q�VP FlLE'W�l'ht -_
<br />THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEM, VITAL:�1'A���T�Wff1�1q;,19
<br />THE LEGAL DEPOSITORY FOR VRAL RECORDS. -=� - -`_ <� `� ^ 9 -
<br />- - � �'r-'Q �
<br />0
<br />DATE OF /SSUANCE _ � ' s � `
<br />�E�. � � ���� � = � � = �a�►c�► s-�v�P� ._
<br />� - - -- ---- _ - -
<br />- - = .a�s��r�r����,�� =--- --
<br />�..L/NCOLN, NEBRASKA 2 � � 2 � 3 4 � ; � � _ #��#I Al{!D N11�1.4AL�'F$�l�F$ ,
<br />8TATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER1ff� �N�'AIdCEAly�7PPORT �}
<br />CERTIFICATE OF.DEATH ,: -= - O 7 9 9
<br />F,7 1.DECEDENT'3•NAME (Flrat, Mlddle, Last, � SuNlx) ' 2.9EX' 3.DATEOFDEATH(Mo„Day,Yr.)
<br />i'� Maril n Jean Bockmann Femal,e Januar 28 2006
<br />���!
<br />��:� 4. CITY AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH 6a. ADE•Last Blrthday bb. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Dey, Yr.)
<br />�;,*< (Yre.) MOS. DAYS HOUflS MIN3.
<br />Shelton, Nebraska
<br />7. SOCIAL SECURITY NUPABER
<br />505-54-4492
<br />Bb. FACILITV•NAME (fl not Inatltotion, give atreet and number)
<br />3858 W. Wood River Rd.
<br />8c. CITY OR TOWN OF DEATH (Include Zlp Code)
<br />Grand Island 68803
<br />9a.RE31DENCESTATE 8b.00UNtY
<br />Bd.STREETANDNUMBER
<br />6�
<br />8a PLACE OF DEATH
<br />HOSP�TAL:
<br />February 6, 1945
<br />❑ Inpatient 9� 0 Nureing Home/LTC ❑ Hoaplce �acllfty
<br />O ER70uipallant � DaceCeM's Home
<br />❑ Dp1 ❑ Oiher(SPecnY)
<br />8d. COUNTY OF DEATH
<br />Ha11
<br />80. CITYORTOWN
<br />Grattd Island
<br />9e. APT. NO 8t. LP CQDE Bg. INSIDE CITY LIMITB
<br />�QQ/�� ❑ YES � NO
<br />10a. MARITAI STATUS AT TIME OF DEATH � Married ❑ Never Merrled 10b. NAME OF BPOU3E (Firel, Middle, Lest, Su(tix) If wite, giva melden neme.
<br />❑ MaMed, but separeled 0 Widowed ❑ Dlvorced ❑ Unknown
<br />Dale Bockmann
<br />71. FATHER'S-NAME (Flret, Mlddle, Last, Suf11x) 72. MOTHER'S-NAME (Flret, Middle, Meiden Surname)
<br />M.rl Hadenfeldt Ma.rcella Richards
<br />13. EYER IN U.S. ARMED FORCE81 Oive detes ot eervice N yea. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yes,no,orunk.) No Dale Bockmann Husband
<br />15. METHOD OF DISPOSITION 18e. EM •SIQNATU 18b. LICENSE N0. 18c. DATE (Mo., Dey, Yr. )
<br />g]eur�a� ❑nonation ry 1191 Jan. 31 2006
<br />❑Cremetlon ❑Entombment 18d.CEMETERY,CREA�ORYOROTHER 0 CIl'Y/TOWN STATE
<br />❑Removel ❑Other(Specity) Westlawn Memorial Park Cemetery Grand Island, Nebraska
<br />17a FUNERAL HOME NAME AND'MAILINO ADDRESS (SUeet, City orTown, Stete) ' 17b. Zip Code
<br />Livin�ston-Sondermann Funeral Home, 601 N. Webb Road, Grgnd Island, NE 68803 ,
<br />1& PART I. Enter the chain of evenis-diseases, Injuries, or complloeNona-thal dfrecGy ceuaed the death. DO NOT enter terminal evente euch ea cerdlec erteal, � APPROXIMATE INTERVAL
<br />reaphstory arreat, m ventriculer flbrllletlon without stmwing the etlology. DO NOT ABBREVIATE. Enlar only o� ceuse on a Iine. Add eddiUonel linea M neceasery. �
<br />IMMEDIATECAUSE: � ' � � onaettodeath
<br />IMMEDUITECAUSE(Flnel X( � �r`C�" v'►.�1�.�' ��"°C..�,� i � i/ � � e Q
<br />diseasemcondidonreaultl� DUETO,ORASACONSE�UENCEOF: I onsettodeath
<br />hl dath) ;� I
<br />SequeMlelly Ilat condltiona, If ro� i
<br />����������� DUETO,ORASACONSEQUENCEOF:
<br />on Iine a.
<br />ENer Nre UNDERLYWO CAUSE
<br />(diseasearinJurythalirddated �°�
<br />��' DUETO,ORA3ACONSE�UENCEOF:
<br />UISI'
<br />I onset ta deflth
<br />I
<br />i onaet M death
<br />I
<br />(� �
<br />78. PAR7 �I.OTHER SIGNIFICANT CONDRIONS-CondiUons contrt6uGng to the deaih bul not resutGng In the underlyi� ceuse ghren in PAR71. 18. WA3 MmICAL EXAMINER
<br />� d OR CORONER CONTAC7ED?
<br />1 � � �.SCL ❑ YE8 � NO
<br />�20. '� 21e NE OFDEATH 21b.IFTRAN9PORTATIONINJURY 21c.WASANAUTOP3YPERFORMED?
<br />D(Not pregnant within past year eturel ❑ Homicide C1 DrlvedOperator .Y �._,/+
<br />❑ YES B�(NO •
<br />❑ Pregnant at tlme of death ❑ Accldent0 PeiMing ImesUgaflon � P��e�ar ��
<br />0 Not pregnanl, bul pregnanl wNhin 42 deys of death � P � e �� 21d WEHE AUTOPSY FINDINQ3AVAILABLE TO
<br />❑ Suldde ❑ CoWd irot be determined � p�er (SDeo�h')
<br />❑ NWpregnent,butpregnen143daystotyearbeloredeaih COMPLETECAUSEOFDEATFI7
<br />❑ Unknownflpregnentwithlnthepaetyear ❑ YES ❑ NO
<br />- 2^�DA�E_FlN.lURY (Mu., Qay,Yr.) 22tr. TI!A5 OF INJURY 22c. P�CE OF I.^1JUAY-A! irome, tarm, street, tscto�, o4ke N�I�ing, nn�stmcNon ai:e, e1c.lSFecNy)- --
<br />m
<br />22d.INJURYATWORK9 22e. DESCRIBE HOW INJlIRYOCCUHRED �
<br />❑ YE9 ❑ NO
<br />22t. LOCATION OF INJURY - 9TREET & NUMBER, APT. NO. CIT(/fOWN
<br />gT1Qp ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIONED (Mo., Dey, Yr.) 24b.17ME OF DEATH
<br />,�� January 28, 2006 ,�� � m
<br />g 23b. TE aNED � M q .,D � ey,Yr.J 23c.TIMEOFDEATH ��� 24o.PRONOUNCEDDEAD(Mo.,Dey,Yc) 24dTIMEPRONOUNCEDDEAD
<br />a�� �" •. lN� 1:20 m a�a� m
<br />'�' �� 23d.To the beat of my knowledge, deafh occurred et the time, date end place � u� � 24e. On the basis of exeminatlon emllor InveatigeUon, in my oplr�on deaih axurred et
<br />� e X end duB1e e ceuae(s) teted. Signature and TIUe )♦ .� p� the tlme, date artd place end due to tlte ceuee(s) stated. (Signature end TiUe )♦
<br />'°-� �.. ~$` .
<br />` o
<br />25.DIDTOBACCAUSE NTRIBUTETOTHEDEATHI 28a.HA80R0ANORTISSUEDONATIONBEENCONSIDERED9 28b.WASCON3ENTORANTED?
<br />�- �r- x
<br />❑ YES C ❑ PROBABLY O UNKNOWN ❑ YE8 NO Not Appllcable If 28e Is NU ❑ YE8 NO
<br />27.NAME.TISLEANDADDRE330FCERTIFI6R fPHY31CU1N.CORONER'SPHYSICIANORCOUNTY T_TORNEYI OYpeorPdnt) P . , ..�.. . ,,,..,_ '...
<br />28a. REGI9TRAR'S SIONATURE
<br />��
<br />0
<br />2Bb. DATE FILED BY REOISTRAR (Mo., Day, Yr.)
<br />FEB �.2006
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