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To be completed /verified by: FUNERAL DIRECTOR I <br />1. DECEDENTS -NAME (First, Middle, Last, Suffix) <br />Leonard Lee Boltz <br />2. SEX f - <br />MAle <br />3. DATE OR DEATH (Mo., Day, Yr.) <br />May 3, 2015 ,. <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Grand Island, Nebraska <br />5a. AGE - Last Birthday <br />(Yrs.) <br />77 <br />5b. UNDER 1 YEAR <br />Sc. UNDER 1 DAY <br />6. DATE OF BIRTH (Mo., Day, Yr.) <br />March 8, 1938 <br />MOS. <br />DAYS <br />HOURS- <br />- MINS. <br />7. SOCIAL SECURITY NUMBER <br />506 -50 -8326 <br />8b. FACILITY -NAME (If not Institution, give street and number) <br />CHI Health St. Francis <br />8a. PLACE OF DEATH <br />HOSPITAL IN Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility <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 />3838 North 70th Road <br />9e. APT. NO. <br />9f. ZIP CODE <br />68803 <br />9g. INSIDE CITY LIMITS <br />❑ YES ® NO <br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married <br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown <br />1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name <br />Lorraine K Madsen <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />Fred Boltz <br />12. MOTHERS-NAME (First, Middle, Maiden Surname) <br />Edna Rauert <br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. <br />(Yes, No, or Unk.) Yes 05/26/1957- 04/25/1959 <br />14a. INFORMANT -NAME <br />Lorraine K Boltz <br />14b. RELATIONSHIP TO DECEDENT <br />Spouse <br />15. METHOD OF DISPOSITION <br />® Burial ❑ Donation <br />❑ Cremation 0 Entombment <br />❑ Removal ❑ Other (Specify) <br />16a. EMBALMER - SIGNATURE <br />Tracey Dietz <br />16b. LICENSE NO. <br />1328 <br />16c. DATE (Mo., Day, Yr.) <br />May 9, 2015 <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE <br />Westlawn Cemetery Grand Island Nebraska <br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) <br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska <br />17b. Zip Code <br />68801 <br />To be completed by: CERTIFIER <br />1 1 <br />CAUSE OF DEATH (See instructions and examples) <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 />Days <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) Post Obstructive Pneumonia <br />disease or condition resulting <br />in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death <br />Sequentially list conditions, if b) Squamous Cell Carcinoma Of Lung With Metastasis To Spine Related To 1 Months <br />any, leading to the cause listed Asbestosis - service Related 1 <br />1 <br />on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death <br />Enter the UNDERLYING CAUSE c) Tobacco Abuse 1 Years <br />(disease or injury that initiated <br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death <br />LAST d) 1 <br />1 <br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. <br />Asbestosis, Chronic obstructive lung disease, Dysphagia <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />❑ YES ® NO <br />). IF FEMALE: <br />❑ Not pregnant within past year <br />9 <br />0 Pre nant at time of deatA <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 />❑ Accitlent ❑ Pe gation <br />❑ Suicide ❑ Could not be detemiined <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. INJURY 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 />To be completed by <br />MEDICAL CERTIFIER <br />ONLY <br />23a. DATE OF DEATH (Mo., Day, Yr.) <br />May 3, 2015 <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 />May 8, 2015 <br />23c. TIME OF DEATH <br />05:35 PM <br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) <br />24d. TIME PRONOUNCED DEAD <br />3d. To the best of my knowledge, death occurred at the time, date and place <br />and due to the cause(s) stated. (Signature and Title) <br />Jay C. Anderson, MD <br />24e, On the basis of examination and/or investigation, in my opinion death occurred at <br />the time, date and place and due to the cau e(s) stated. (Signature and Title) <br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />0 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN <br />26a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED? <br />❑ YES 0 NO <br />26b. WAS CONSENT GRANTED? <br />Not Applicable if 26a is NO ❑ YES ❑ NO <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print <br />Jay C. Anderson, MD, 729 North Custer Avenue, <br />Grand Island, Nebraska, 8803 <br />28a. REGISTRAR'S SIGNATURE <br />I <br />28 b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br />May 8, 2015 <br />DATE OF ISSUANCE <br />05/11/2015 <br />STATE OF NEBRASKA <br />2 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKkbARI OF HEALTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR '16ITt9f.i QRrD t <br />n^ «K <br />ST /NLEY S...CQPPER . ` <br />.A$SIS STATE REGISTRAR <br />DEPA T,,{ l EAL7 -I AND <br />LINCOLN, NEBRASKA ,HUMAP <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEJtb7C <br />CERTIFICATE OF DEATH I'r <br />