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200107245 Rev. 11/97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH z W 0 W U W O LL O W Q z of M FOR VITAL STATISTICS USE ONLY Place ....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part II ...................... TMV ........................ .. NSC...................................................................................................................................................................... ............................... .........................Census Tract No .......... . ........ . Work...................................................................................................................................................................................................................................................... ............................... UC ........................................................................................................................................................................................................................... ............................... Reject................................................................................................................................................................................................................... ............................... aPrinted with troy Ink on recycled Paper i -C2 r 11 I. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Mona+, Day. YNIr) Lillian Bertha Boernke Female October 27, 1998 •. CITY AND STATE OF BIRTH land h U SA., hems coontryl AGE. Last Birthday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIRTH /MoeM. Day Yaarl MOS DAYS 77771 Wausau, Wisconsin 15s. (Ural 97 5b 7 April 4, 1901 7. SOCIAL SECURTIV NUMBER Be PLACE OF DEATH 389 -22 -4581 HOSPITAL: ❑ Inpatient OTHER: ® Nursing Home - -- - ❑ ER Outpatient ❑ Readance bb. FACILITY - Name Ia not msanmar, give street and numbeir) ❑ DOA ❑ Other /Specify, Lakeview Nursing Home Sc CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yee ® No ❑ I Hall 9e,. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Includeng Zip Cod) 9e INSIDE CITY LIMITS Nebraska I I Hall Grand Island 11405 W. Highway 34 68801 Yes[] No ❑ 10. RACE - (a p., Whim. Black. American Indian. 11. ANCESTRY le g.. Italian. Mexican. German, etc) 12. ❑ MARRIED r-$ WIDOWED 13. NAME OF SPOUSE IN wise. give, makM name,) etc.)(Spectyl White (Spec,Iy) American NEVER L- jDIVORCED Edward Boernke tea. USUAL OCCUPATION 10" kind of work done Ong most tab. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify cohtproMd) Ebmentary or Secondary 10.121 C~ It -a 0, 5.1 of wwkrng Ids. even it reared) Homemaker Domestic 12th grade ill FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Edward NMN Kafahl I Otillie NMN Nickel 16. WAS DECEASED EVER IN U.S. ARMED FORCES? 1ga, INFORMANT -NAME (Yee. no. or unk.) 1e, yes . give war and dates d servicesl No - -- Ruby Bissell 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO,. CITY OR TOWN. STATE. ZIP) 1031 E. Bismark, Grand Island, NE 68801 E BALMER . SIGNATURE 6 LICENSE NO 21a METHOD OF (NSPOSITION 21b. DATE . CEMETERY OR CREMATORY NAME 114a ©Burial ❑Removal 10 -30 -98 7westlawn Memorial Park 22a. FUNERAL HOME -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston - Sondermann F.H. ❑Cremation 1:1Donakon Grand Island NE 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 601 N. ebb Road, Grand Island, Ne. 68803 -4050 23. IMMEDIATE CAPS (ENTER ONLY ONE CAUSE PER LINE FOR Ial. to). AND c1l i Interval onaat and seam r ' PART let \' I� '�,•- DUE TO, OR AS A CONSEQUENCE OF l Intarvat between and deem tv DUE TO. OR AS A CONSEQUENCE OF I Interval belwean chase and dl 1 I (c) I OTHER SIGNIFICANT TONDITIONS - Cmditlons X Ibuti a the death but rat related PART PART r PREGNANCY III IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS? 2d AUTOPSY L 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? `y-c 0 -C.i 1 + t )Ages 10 -511 Yes No VN No VM No 26a. 26b. DATE OF INJURY (Md. Day. Yr) 26c HbUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED C] Accident ❑ Undetermined M El Suicide Pending - 28a. INJURY AT WORK 26f. ofire bu%INN,JUR� • N h � , )arm. aheel. )story /Spat 26g. LOCATION STREET OR R.F.D. N0. CITY OR TOWN STATE Homicide Investigation Ves ❑ No ❑ 27a DATE OF DEATH (MC. Day yr) 26a. DATE SIGNED (A 110, Day Y,1 2 TIME OF DEATH Bb X ` 1'4 x) V ny M • E Y a 27b DATE SIGNED Me.. Day Vrl 27c TIME OF DEATH 26c. PRONOUNCED DEAD /Md.. Day, YO 2Bd. PRONOUNCED DEAD /Mast 2: 00 P. M M 27d ToMy beat d my NnoMAedge, death occurred N ems, daro geca and due b the 2Ba. On to bola d ax�rninatton and tx Invagigaaon. ro my d9koph death t1eCYlgd at • S Its �aGeelat stated. / l r w bro ame, date, and place end due, to Ste towels) Naiad. (Sightless and Title aaae NM Two 29. DID TOBACCO USE CONTRIBUTE TO TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED'+ ❑ YES )/ ^NO ❑ UNKNOWN YES ___ � ❑ YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEVI IType or Plot WILLIAM J. LANDIS M.D. 2444 W. FAIDLEY GRAND ISLAND NE 6881713 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR 14411p. Day. Yr./ FOR VITAL STATISTICS USE ONLY Place ....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part II ...................... TMV ........................ .. NSC...................................................................................................................................................................... ............................... .........................Census Tract No .......... . ........ . Work...................................................................................................................................................................................................................................................... ............................... UC ........................................................................................................................................................................................................................... ............................... Reject................................................................................................................................................................................................................... ............................... aPrinted with troy Ink on recycled Paper i -C2 r 11