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I. (1ltttla�.. SAWA nit P/#441141 WHEN THIS 'I ' 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 3/4/2019 LINCOLN, NEBRASKA 201905656 RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH • 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. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Timothy Joseph Bogner 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) February 23, 2019 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 53 MOS. DAYS HOURS MINS. December 31, 1965 7. SOCIAL SECURITY NUMBER 505-04-7477 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility Eb FACILITY -NAME (If Pot Institution, give street and number) ICH) Health St. Francis 0 ER/Outpatient 0 Decedent's Home 0 DOA. 0 Other (Specify) 'dc. c:iTf OR TOs OF DEATH ji,,ci::oa Zip Cede;led. COI 'PITY OF DEATH Grand Island 68803 I Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island I^ J. STREET AND NUMBER W. 5th St 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ❑ YES 0 NO t�1510 s1a. MARITAL STATUS AT TIME OF DEATH ❑ Married El Never Married I0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name III. FATHER'S -NAME (First, Middle, Last, Suffix) Kenneth Bogner 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Diane Dickey 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. I(Yes, No, or Unit.) No 143. INFORMANT -NAME Todd Bogner 14b. RELATIONSHIP TO DECEDENT Brother 115. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) February 26, 2019 ® Cremation 0 Entombment ❑ Removal Q Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska J 68801 CAUSE OF DEATH (See instructions and examples) 13. PART). Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE NTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line.. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest %Saar: ord, dit:c. rec.:ing I onset to death Minutes in death) DUE TO, OR AS A CONSEQUENCE Sequentialiy het cone riots, c 'b) iv ata3tcto Colon Cancer any, Wading to the cause listed" OF: onset to death I' 6 Months on line a. DUE TO, OR AS A CONSEQUENCE Enter the UNDERLYING CAUSE c) (disease or injury that initiated OF: onset to death the events resuhmgIn LAST; death) DUE TO, OR AS A CONSHQUENCE OF: °:..:. d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. N 19. WAS MEDICAI. EXAMINER OR CORONER CONTACTED? ❑ YES EJ NO 23. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ®NO 0 Not pregnant but pregnant within 42 days of death 0 Not pregnant, but pregnant 42 days to 1 year before death ❑ Unknown if pregnant within the past year ❑ Suicide Could not be determined ❑ ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDIC RL CERTIFIER. 04LY �23a. DATE OF DEATH (Mo., Day, Yr.) February 23, 2019 mpleted by. i PHYSICIAN Y ATTORNEY INLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) February 25, 2019 23c. TIME OF DEATH 12:00 PM 24. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD II 1'21d. To the best of my knowledge, death occurred at tr 1 rn.e, dare an..; ;:: a and due to the cause(s) stated. (Signature and Tine) Shu -Ming Wang, MD 3 i V c 6 p ~;$ 5 ±a., On the basis of examination and/or investigation, in my opinion death occurred at tud. (Sier.ctc a and Title) the ane, aa: and place an: sue to iiia -_a : ts 25 DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 0 NO 0 PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ®NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 7. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Shu -Ming Wang, MD, 908 North Howard Avenue Ste 109,=;Nebraska, :8a. REGISTRAR'S SIGNATURE e ------February 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) 27, 2019 ''�`'� -