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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF.MEAl.I'W "A F HUMAN SERVICES' IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE414;4710,0EPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 4'TTAL •RE,CORBS;
<br />DATE OF ISSUANCE
<br />AUG 26 2014 201405418•
<br />LINCOLN, NEBRASKA
<br />.§TANLEY, $COOPER
<br />3 I A S,SIS7 REGISTRAR
<br />. AR'rMEN'r'OF HEALTH:AND
<br />MAN SERVICES'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANSERVICMS : Li
<br />CERTIF CAT OF r, a
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<br />1. DECEDENTS -NAME (Filet, Middle, Last, Suffix
<br />Darold Phillip Bohl
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508 -18 -9439
<br />8b. FACILITY-NAME (ti not Institution, give street and number)
<br />Veterans Affairs Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND NUMBER
<br />224 South Kimball
<br />10a. MARITAL STATUS AT TIME OF DEATH _ El Married ❑ Never Manfed
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Sa. AGE-Last Birthday
<br />(Yre.)
<br />85
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Phillip Bohl
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Male
<br />HOURS
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ®Inpatient
<br />❑ ER/outpatIent
<br />❑ DOA
<br />OTHER: ❑ Nursing Home/LTC ❑ Hospice Faculty
<br />❑ Decedent's Home
<br />❑ Other(Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />5c. UNDER 1 DAY
<br />MINS.
<br />)C1e.,Day.Yr.)
<br />January 4, 2011
<br />6.
<br />DATE OFBIRTH (MO Day, Yr.)
<br />July 22, 1925
<br />9f. ZIP CODE
<br />' 68801
<br />9g. INSIDE CRY LIMITS
<br />® yes 0 No
<br />10b. NAME OF SPOUSE (First, Min Lest, Suffix) N wife, give maiden mane.
<br />Virginia Wanitschke
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Margaret Uebsack
<br />13. EVER IN U.S. ARMED FORCES? Give dates of serWee If Yes. 14a. INFORMANT -NAME
<br />(Yea, No, or unk.) Yes 02/25/1944 Virginia Bohl
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />®BUMI ❑DOMtion
<br />❑Dematton ❑Entemhmue
<br />❑Removal ['Other/Specify)
<br />lea. EMBALMER- SIGNATU
<br />Grand Island City Cemetery
<br />18b. LICENSE NO.
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN
<br />0 j
<br />Grand Island
<br />160. DATE (Mo., Day, Yr.)
<br />January 6, 2011
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />it PART L Enter Ow elms wAIDOM diseum, h4wt.., w complications- Mg dimity canard Ow deal. DO NOT enter boning wont, sues as uMlacmut.
<br />respiratory smst, w ventricular fibrillation mahout showing IM eliotogy. DO NOT ABBREVIATE. Enter only one cause on a IIM. Add addieons aas If neeaary.
<br />A IMMEDIATE CAUSE
<br />IMMEDIATE CAUSE (Final n
<br />i nse ahh ) ase rhul
<br />condition resulting a) 1 " ∎LI I Cr ' T kJ\ fTVILAINc
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />br
<br />Sequentially list conditions, N
<br />any, leading to the cause listed
<br />on Dne a.
<br />Enter the UNDERLYING CAUSE
<br />k DUE TO, OR AS A CONSEQUENCE on
<br />onset to death
<br />x
<br />onset to death
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />d) Aden 0 r (MCC: ►n ©ten o`1 the s%
<br />onset to death
<br />jeeS. PART D. OTHER SIGNIFICANT CONDmONScondIuons contributing to the death but ntA resWTing inthe underlying cause given In PART L
<br />�ern�n�ieL CocoAaV\ cu e.c
<br />20. IF FEMALE
<br />❑ Not pregnant within past year
<br />❑Pre 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 dead.
<br />❑Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (140., Day, Yr.)
<br />22d. INJURY QT / WORK?
<br />❑ YES L am+
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />CITY/TOWN STATE
<br />MP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Jan. 3, 2011
<br />DATE SIGNED (Mo., Day. Yr.)
<br />tc1tAar , ar)
<br />b' •Ne sV.cAe.8 mneu.monia.
<br />DUE TO, OR AS A CONSEQUENCE IF 11A
<br />: l
<br />o' - i`CP�Sk- vin P Ct t�rks lS �o�1 y '7 PC Ciao X -f
<br />DUE TO, OR AS A CONSEQUENCE OF: tt -J
<br />22b. TIME OF INJURY
<br />m
<br />,Jtd. To the be eCB► my knowledge, death occurred at the rime, date and place
<br />and due to the cause(s) stated. (Signature and Mlle)
<br />Cwv
<br />)1<t5. DID TOBACCO USE CONTRIBUTE TO E EATH?
<br />❑ YES ❑ NO ❑ PROBABLY UNKNOWN
<br />28a. REGISTRAR'S SIGMA
<br />t DJ- c
<br />(\'i SeQ S.e 141 r.)ke MO, (1 /' t ri t q
<br />'2 1a NER OF DEATIT 21b. IF TRANSPORTATION INJURY
<br />Natural ❑ Hadclde ❑ Driver/Operator
<br />❑ dent ❑ Pending investigation ❑ Passenger
<br />❑ Suicide ❑ Could not be determined ❑ Pedestrian
<br />❑ Other (Specify)
<br />230. TIME OF DEATH
<br />5:00 a m
<br />220. PLACE OF INJURY -At hone, farm, street, factory, office building, construction site, etc. (Specify)
<br />►l(
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />r te. HAS ORGAN OR E D NATION BEEN CONSIDERED?
<br />❑ YES NO
<br />17b. Zip Code
<br />68803
<br />WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES
<br />NO
<br />24a WAS AN
<br />❑ YES
<br />PERFORMED?
<br />NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES ❑ NO
<br />24b. TIME OF DEATH
<br />m
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On the basis of examination anwor investigation, in my opinion death occurred
<br />at the tine, date and place and due to the cause(s) stated (Signature and 110e)
<br />A8b. WAS CONSENT GRANTED?
<br />Not Applicable If 20a 1s NO ❑ YES
<br />47. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,.PNYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) 4301 (1 w Print)
<br />° a�h�een {�c Y�mr �01 /v broadt>Jel C- ,ranrl rs oLnrl Npbras 1 n tYi
<br />I Co , Pl
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JAN 1 0 Z011
<br />1
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