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STATE OF NEBRASKA �....
<br />l to
<br />4a
<br />2 SE%
<br />Male
<br />Pa3? ;.J
<br />' 4 Cif
<br />DEATH (Inchute ZiP Co
<br />8803
<br />iDENCE -STATE 9b. COUNTY
<br />(Yrs
<br />Nebraska Hall Donlphan
<br />APT. NO. 6r, ZIP COOS Sg. 1144104 :.ITV LIM(TS
<br />9d, ST HE:Y,T ANON NOISIER 68832 Y es'Ntl
<br />62
<br />W.: plitnej' Rd
<br />�r
<br />1 AIARITAS STATUS 41 TIME OF ()EAT W Mawned L , t Never Marrie¢i tats NATaE iii' $POI ISE (frost, Mrricfls, Liwt, S,Hfix) t wHe give maiden name.
<br />0 Married, but separated O'Welowed 0 Divorced 0Unknown Joyce Al Boltz.
<br />Fi rst , Middle, Last, Softie) . • 12- w r47»R'S.Ik8Mf (First. middle, Maiden S umamai
<br />,P 4 1 1rf1arl CJ :tchafer' ;' Aileen ..Q C13T` nor
<br />14b. RELATXONSMIP T pECEDB
<br />PV FORE, ER fN tl.S- ARMED FOR Y'tee dates of servira H Yes. 148. INFORMANT Er
<br />O a
<br />— (Yea. Na, or Unk.) No Joyce A Schafer )
<br />1 S� METNOO OF DISPOSITION ✓ 16a. FMBAS. ER -SIG JATURP: a i
<br />104844 NO. 16a. D ATE (MO., Day, Y11
<br />1153.4 �Ix 84 0
<br />.
<br />,, v _, , .•,y 23, `2016
<br />,aaatrar nitanamo,rwne 1 t'dTYttOWN STAT
<br />CEMF» »VERY, R
<br />CEIRATL)FIY OR OTkif:Yi k0C;ATION
<br />t iltwraral 00000(Somity)
<br />Ceea v;eW Cemett ry Doniphan Nebraska
<br />1111 Zip cede
<br />11a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town. store) 68801
<br />Ccrtsan rz ral Chapel, 3005 S. Locust St , Grand Island, Nebraska '
<br />Sp iM1tm'y arrsvt» n^ veaffile fibraistial: wnnnbn aowin 1 '.
<br />IMMEDIATE CAUSE,
<br />arluane;airy tise candltlom, tf 41
<br />toy, lea(4o2)4 to the cause listed
<br />a. DATE 0F. 0EA71�) (Mo., Day, Yr.)
<br />Ju ne 19, 2016
<br />ATE. SIGNED ..(Mo.,
<br />2016
<br />CAUSE OF DEATH (See instructions and exam +les)
<br />mVUaationa tt
<br />IDT A8611V)*1e. Fnenr o(1 o cn,
<br />DUE: T O R AS A CONSEOUENC
<br />8)4144vlNO CAUSE c)
<br />Barry that in' sated
<br />salting in UAAU1) DUE TO, OR AS A CONSEQUENCE OF;
<br />ICANT CONDITIONS-Coo 1
<br />JtfRY A, T �., V�O, Ri(7 22a. DES 'Ft)44 14014 INJURY OCCURRED
<br />YES I1YNt1
<br />LOCA Yit13T 08 44 4URY . STREET 8 NUMBER, AM, NO
<br />M !try knnwta4$Ia daati occurred at. Ina
<br />•' sone( a)siate . {SI!= -stars and Title'
<br />KA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />T T • D A H
<br />a 4he nezin bur niri re%VFtkn
<br />NNER OF DEATH
<br />egronnt at 1YYe O of death U Amclda 1 LJ 1461)4(14
<br />T pra944.144 pro9nant wiaMn 42 days of deoth 0 Ste cnie 0 Clsula r•
<br />t c+reUnarit, 1'sut 4) 44100* 48 days to 1 Year 1efnre death
<br />6188414 Spr4Nnari8 within the past year
<br />OAS E 0P 44UHT (M0,, Day, Yr.) 22b. TIME OF INJURY 226. PLACJE'.O i1
<br />11:45 a1 >
<br />NOE
<br />M08.
<br />3444 HOURS MINS.
<br />R 5c. UNDER 1 DAY
<br />a4d a4dianao: 446(8 !t
<br />j Nrarning Horo<
<br />1)0co 4ent ' s Morose
<br />D Ot;ots(SPwa!t )
<br />Ad. 0014 OF D EATM
<br />Hall
<br />14141
<br />sa ah'an in PART I.
<br />Vb. IF TRANSPORTATION INJURY
<br />Dt
<br />i4ation 0 passenger
<br />08 ,141 U Pailestriaro
<br />Olilw ISpncifyl
<br />1. DATG OF 0EATH
<br />June 19, 2016
<br />6.
<br />AT OF Si (!
<br />June 3, 194
<br />19. WA EO(CAL
<br />OR CORONER CC),
<br />21d. WERE AUTOPSY FINDING!
<br />TO COMPLETE CAUSE *24
<br />O YES
<br />ltrs Yavrli, srfraeT,..faetaxy, alike tetilr461, canatraction Fite, etc. (
<br />STATE
<br />246. DA'8E S(GNE0 (Ma., Day, Yr.) 241. TIME 0
<br />248. PRONL7UNCED 06407,Mg., D.y, Yr.) 24d. TIME PRONOUNCE)) 8)480
<br />Gaais oCaBASninoNOn a,dfor 44444*i4
<br />into, date and PMee And duo to t118 aaUae(s) sS
<br />APPROXIMATE INY"E4'H)8
<br />onset to death
<br />ot1 &at I
<br />a., Day. Yr.) ,I
<br />tad;,(
<br />OILY 1'Or#AG Y4T .E CONTRIBUTE: TO THE D TH9 26x11444 014124 3 04 314SUC D '16114 Plt^FN CONSfDERE07 764, WAS CONSENT GRANTED?
<br />0' AS A 0 814084814 E l NNOV N [ YE t N35 Nat Applicable H Y
<br />264 Is NO �} ES
<br />i
<br />NAkiE. TPILE AND ADDRESS OF CERTIFIER (Typo or Print)
<br />t., jjyy y1 Al ee an. r 4L4 d NE, §8803
<br />'�p+t TRAR' P7�gOr�Q1: f� `t D e © 201. DATE FILED BY REGIS f RAR 184 4ay Yr 1
<br />RE GLSTRAR`S SIGNATURE
<br />AVA1t;A8t F:'
<br />DEATH?:
<br />1at71ro #Ina T+
<br />WHEN THIS • COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORYFOR VITAL RECORDS
<br />DATE OP ISSUANCE
<br />06/29/2016
<br />LINCOLN, NEBRASKA
<br />A
<br />eley, Uebrask
<br />U
<br />6h. FACILITY -NAME (H not )
<br />'eci9ewood
<br />C5'1 OR Ta
<br />F� y
<br />STATE OF NEBRA
<br />R TERRITORY, OR FOREIGN COUNTRY OF AIR:
<br />atl. (1 iv 0 street And number)
<br />6M? 81. 08 P
<br />201608810
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />
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