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<br />(.6y STATE OF NEBRASKA
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<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 DEPOSITORY FOR VITAL RECORDS if
<br />RUSSELL FOSLER
<br />INTERIM ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSSUANCE
<br />LINCOLN NEBRASKA
<br />18 13176
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Ruth Ann Boeka
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 11, 2018
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Oak Park, Illinois
<br />5a. AGE - Last Birthday
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.)
<br />83
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />April 19, 1935
<br />7. SOCIAL SECURITY NUMBER
<br />:..507-34-6476
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />The Ambassador Lincoln, Inc.
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility
<br />ER/Outpatient ❑ Decedent's Horne
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68506
<br />Bd. COUNTY OF DEATH
<br />Lancaster
<br />9a. RESIDENCE -STATE
<br />Nebraska `"
<br />9b. COUNTY
<br />Lancaster
<br />9c. CITY OR TOWN
<br />Lincoln
<br />9d. STREET AND NUMBER
<br />4405 Normal Blvd.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68506
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL
<br />❑ Married,
<br />STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />but separated ® Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Hight
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Virginia Hermes
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME-.
<br />Janet Warner
<br />14b. RELATIONSHIP TO DECEDENT..
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />October 16, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />BML Cremation Service Lincoln Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Butherus-Maser & Love Mortuary. 4040 A Street. Lincoln. Nebraska
<br />17h. Zip Code
<br />68510
<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 />respiratory arrest, orventricular 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)Cardiac Pulmonary Failure
<br />disease or condition restating
<br />M death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially hat conditions, 8 .: b)Atria( Fibrillation
<br />any, feadmg 10 the cause listed'
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Hypertension
<br />(disease or injury that initiated
<br />"'jars resuxrnq m death) DUE TO, OR AS A CONSEQUENCE OF:
<br />`AST d)Vascular Dementia
<br />APPROXIMATE INTERVAL?
<br />onset to death
<br />Minutes
<br />onset to death I'
<br />Years
<br />onset to death
<br />Years
<br />onset to death
<br />Years
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Adult Failure To Thrive
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />1:10 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant43 days to 1 year before death
<br />0 Unknown itp;eqnantwit)in the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />Accident ❑ Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />❑ suicide ❑Gould not be determined
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY
<br />ATWORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />(
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<br />Zia...4TE i,"47- DEATH (iviesY
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<br />October 11"2018
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<br />24a. DATE SIGNED (Mo., uay, 7r.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />October 15,2018
<br />23c. TIME OF DEATH
<br />01:25 PM
<br />4 s k
<br />Ey`z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />a
<br />2 o
<br />o
<br />2
<br />0 23d. 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 />Jill S McAdam, PA
<br />1 8 W i O
<br />a 2 0
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<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 cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jill S. McAdam, PA, PO Box 22359, Lincoln, Nebraska,
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />68542
<br />28a, REGISTRAR'S SIGNATURE _
<br />�%'�I-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 16, 2018
<br />- "
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