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tz ... ,. STATE OF NEBRASKA 1, DECEDENTS -NAME (First, Middle, Last, Suffix) William Boersen Q K a ttl z. u. w .0 d f, WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 11/27/2017 LINCOLN, NEBRASKA 4. •CITY<AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505-44-4032 8b. FACILITY - NAME (If not Institution, give street and number) CH1 Health 5t. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 sa. RESIDENCE -STATE 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 3551 Laura Ave 11,FATHE Henry 46a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, or Link.) No Laura Boersen 2 15. METHOD OF DISPOSITION 16a. EMBALMER - SIGNATURE ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other :(Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska 1a. PART'. Enter fee chain of everts- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory array-, or ventricular fibrillation without showing the etiology. 00 NOT AssttevIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: 'S- NAME (First, Middle, Last, Suffix) Boersen IMMEDIATE CAUSE (Final a) Asystole disease or condition resulting n death) Sequentially list cer) d tic any, leading to the itsteii on line a. Matthew T. Myers DUE TO, OR AS A CONSEQUENCE OF: b)Acute myocardial infarction DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c). tdiseaee or mtury tf(at in(tiated the events resulting: in death) LAST'< 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Past History Of Cardiac Disease 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 0 Not pregnant, b ut pre9nant wit ❑ Nbt pr hin 42 days of death e gnam, , t r ut p 4S days 10 1 year before death 1-.-,„.,L, nnown if pregnant 4thitithe past year 22a. DATE OF INJURY (Mo., Day, Yr.) .0 22d. INJURY ATWORI4? 22e. DESCRIBE HOW INJURY OCCURRED F 0 YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. E 0 2 u al 0 Era 230. DATE OF DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 20170842p STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23c. TIME OF DEATH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR (Yrs.) MOS. DAYS 81 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ® ER/Outpatient ❑ DOA 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Laura 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Memorial Park Cemetery Grand Island CAUSE OF DEATH (See instructions and examples) CITY/TOWN 9c. CITY OR TOWN Grand Island` 9e. APT. NO. STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 5c. UNDER 1 DAY HOURS OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other(Specify) 8d. COUNTY OF DEATH Hall 6b. LICENSE NO. 1411 9f. ZIP CODE 68803 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Eliza Kuhl 21h, IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) STATE MINS. 3. DATE OF DEATH (Mo., Day, Yr.) November 8, 2017 6. DATE OF BIRTH ; May 4, 1936 ❑ YES ® NO onset to Minutes ❑ Hospice Facility 9g. INSIDE CITY L #NITS' II YES ❑ NO 14b. RELATIONSHIP TO DECE Wife 16c. DATE (Mo., Day, Yr.) November 13, 2017 STATE Nebraska 17b. Zip Code ' 68803 onset to death onset to death' APPROXIMATE INTERVAL:. onset to 4e01 Seconds 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES .0410 21c. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE 'OF DEATH?, ❑ YES ❑NCT 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH November 17, 2017 Approx. 12 :50 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD November 8, 2017 12:51 PM 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Ashley A. Dorwart, Deputy Hall County Attorney 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ ' 25. DID TOBAGO() USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ashley A, Dorwart, Deputy Hall County Attorney, 231 South Locust Street, Grand Island, Nebraska, 68802 28a. REGISTRAR'S SIGNATURE f`) ` /� w /�C 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 20, 2017