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To be completedNerified by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Maynard Albert Boltz
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 11, 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hall County, Nebraska
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />87
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />March 3, 1925
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />506 -32 -8242
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility
<br />8b. FACILITY-NAME (If not Institution, give street and number)
<br />St. Francis Memorial Health Center LTC
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1810 S. Blaine St.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />0 YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Lila Jean Scheel
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Albert Boltz
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Augusta Wiese
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 06/25/1945 - 12/12/1946
<br />14a. INFORMANT -NAME
<br />Karen Sue Autrey
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER-SIGNATURE
<br />Matthew T. Myers
<br />16b. LICENSE NO.
<br />1411
<br />16c. DATE (Mo., Day, Yr.)
<br />June 15, 2012
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />I To be completed by: CERTIFIER
<br />18. PART I. Enter the chain of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Weeks
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Metastatic Cancer To Liver, Unknown Primary, Suspect Pancreas
<br />disease or condition resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, If b)
<br />any, leading to the cause listed
<br />line
<br />on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST d)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS - Condition contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Atrial Fibrillation, CAD S/p CABG, COPD - mild
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES El NO
<br />20.1F FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending lion
<br />❑ Suicide ❑ Could determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. 1NJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />k W
<br />$ }
<br />E 14 z
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 11, 2012
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 2, 2012
<br />23c. TIME OF DEATH
<br />12:45 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />8 u 0 3d To the best of my knowledge, death occurred at the time, date and place
<br />8 c and due to the cause(a) stated. (Signature and Title)
<br />2 Kimberly A. Mickels, MD
<br />24e. On Inc basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO ❑ PROBABLY El UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, HYSICIAN ASSISTANT, CORONER'S PHYSICIA,ITOR COUNTY A (Type or Print)
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />1 28a. REGISTRAR'S SIGNATURE A- /'� - -_
<br />(�OJYRrti'V
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />July 2, 2012
<br />DATE OF ISSUANCE
<br />201303237 " STAAVLEY S et tdpeR, ..../
<br />ASSITANT STATE 2 013 0 3 3 8 3 PAIR,T,ME: T OF HEAL ND'
<br />LINCOLN, NEBRASKA HUM,4/V SFR,ilff f , ;
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES t `: /,
<br />CERTIFICATE OF DEATH
<br />07/05/2012
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN 17 CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEP IjTLNENT OF •HkALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR- V!77IL RC R13S� ' -_ d '
<br />12 02342
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