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I .n , Wr 1 . \ „ti "l/ � . , /u4` 4 M14 ^ s/ DAtetaikM 7..4) STATE OF NEBRASKA tivii$29.9WIPAtaiirr . 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 12/1/2017 LINCOLN, NEBRASKA N ga. RESIDENCE - STATE Nebraska 201803939 j9b. COUNTY l9c. CIT; OR TOWN Hall I Grand Island STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH I avrm STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 0 1- 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Richard LeRoy Boardman 4, CITYANDSTATE OR FOREIGN COUNTRY OF BIRTH Fullerton, Nebraska 7. SOCIAL SECURITY NUMBER 507 -38 -7148 8b. FACILITY -NAM E (If not Institution, give street and number) CHI Health Nebraska Heart ce • 8c. CITY OR TOWN OF DEATH (Include Zip Code) C Lincoln 68526 5a. AGE Last Birthday (Yrs.) 80 5b UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8d. COUNTY OF DEATH Lancaster 3. DATE OF DEATH (Mo., Day, Yr.) November 24, 2017 6. DATE OF BIRTH (Mo., Day, Yr,) October 25, 1937' 8a. PLACE OF DEATH HOSPITAL ® Inpatient 0 ERIOutpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married • ❑ Married, but!separated 0 Widowed ❑ Divorced ❑ Unknown LL 9d. STREET AND NUMBER Y, 4157 W. Airport Road m al 1. FATHER'S-NAME (First, Middle, Last, Suffix) Fred Boardman E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. O (Yes. No, or Unk.) No • r 15. MET HOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) At I 0 v IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Aortic Dissection disease or condition resulting isi .tteot, equeMtlally list Con dl inns, if any, leading to the Cabae hated on line a. y 20. IF FEMALE: l ❑ Not pregnant within past year V ❑ Pregnant at time of death ❑ Not pregnant, but 42 days of death ❑ Not pregnant, Ixit pregnant 4S days to 1 year before death d ❑ tfnknawn if Pregnant within: the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 224: INJURY AT W ORK? •❑ YES ❑NO 23a, DATE OF DEATH (Mo., Day, Yr.) November 24; 2017 23b. DATE SIGNED (Mo., Day, Yr.) November 28, 2017 DUE TO, OR AS A CONSEQUENCE OF: b)Ascending Aortic Aneurysm 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) James H. Wudel; MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 28a. REGISTRAR'S SIGNATURE 16a. EMBALMER- SIGNATURE George Palmer 23c. TIME OF DEATH 09:34 PM 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Etna Sonderup Middle, Last, Suffix) If wife, give maiden name 14a. INFORMANT -NAME Elna Boardman 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Palmer- Santin Funeral Home. 210 Irving Street, PO Box 851. Fullerton, Nebraska 1S. 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, respiratory arrest, or ventricular - fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line, Add additional lines if necessary. 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 26a. HAS ORGAN OR TISSUE ®• AT1 ® YES it NO ON BEEN CONSIDERED? 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Caroline Otlewske 16b. LICENSE NO. 0892 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian __❑ Other (Specify) 24a! DATE SIGNED (Mo., Day, Yr.) 240. PRONOUNCED DEAD (Mo., Day, Yr.) 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) December 2, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Fullerton Cemetery CITY / TOWN Fullerton STATE Nebraska 17b. Ztp Code 68638 CAUSE OF DEATHJ,See instructions and examples) APPROXIMATE:INTERVAL onset to death:: onset to death:, Yearts the events resulting dea th):: hAST DUE TO, OR AS A CONSEQUENCE OF: d) onset to death Enter the UNDERLYING CAUSE tdieease or iniary tINt Initiated DUE TO, OR AS A CONSEQUENCE OF: c) Coronary Artery Disease onset to death Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E] NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OFDEATH? :. O YES 0 N 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH::: 24d. TIME PRONOUNCED DEAD 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), 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print James H. Wudel, MD, 7440 S 91st St, Lincoln, Nebraska, 68526 28b. DATE FILED BY REGISTRAR November 29, 2017 o ,Day, Yr.) 0 N CD