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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
<br />DATE OF ISSUANCE
<br />10/3/2019
<br />LINCOLN, NEBRASKA
<br />202005186
<br />RUSSELL FOSLER
<br />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 />1. DECEDENTS•NAME (First, Middle, Last. Suffix)
<br />Edith Elsie Bonsack
<br />CITY ANO STATE OR TERRITORY, QR FOREIGN COUNTRY OF BIRTH
<br />7. SOCIAL SECURITY NUMBER
<br />500-18-7455
<br />9b. FACILITY -NAME Whet Inatltutlon, give street and number)
<br />Riverside Lodge, Inc,
<br />ba. AGE • Last Birthday
<br />(Yrs.)
<br />95
<br />ea. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ERIQutpatlent
<br />DAA
<br />2. SEX
<br />Female
<br />50. UNDER 1 YEAR Se. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS,
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 20, 2019
<br />9. DATE OF GIRTH (Me., Day, Yr.)
<br />ecember 30 1 3
<br />OTHER 0 Nursing Hems/.TC
<br />0 Deeedent's Home
<br />® Other (Speatry1SSSISTED LIVING
<br />Hospiaa Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d, COUNTY OF DEATH
<br />Hail
<br />9e. RESIDENCE4TATE
<br />Nabrsska
<br />9d. STREET AND NUMBER
<br />t4 Wo dl nd Driv;
<br />10a. MARITAL STATUS AT TIME OF DEATH
<br />0 Married, but separated ® Widowed
<br />$b. COUNTY
<br />Hall
<br />9e. CITY OR TOWN
<br />Grand <Island'
<br />rte. APT. NO.
<br />15
<br />flf. 7JP CQDE
<br />1
<br />Sg. INSIDE CITY LIMITS
<br />IRI Yes 0 NO
<br />Married 0 Never Married
<br />] Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First,
<br />Herbert Bonsack
<br />Middle, Last, Suffix) if wife, Ova maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Earl Fairbanks
<br />I
<br />' 12. MOTHER'S -NAME (First, Middle,
<br />Edith Lomax
<br />Malden Surname)
<br />1
<br />3. EVER IN U.S. ARMED FORCES? Glve dates of service 1f Yes. 14*. INFORMANT -NAME
<br />(Yes, No, or Unk.) No Debra 8rummond
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />I Cremation 0 Entombment
<br />❑.Removal 0 Other(Spsdfy)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />llib. ICENSE NO.
<br />18a DATE (Mo., Day, Vr.)
<br />September 20, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)'
<br />Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17b. ZIp Code
<br />68801
<br />C UskpF Qf.ATB.isje lttstrygtiRAkgnd e)iaplp1ee
<br />[8. PART I. Enasr the:;M14 at events- diseases, Injuries, or compllcetions4hat directly asuited the death. 00 NOT entertarminal events such as cardlae arrest.
<br />respiratory arrest, orr veNAaiilar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one coupe one lire. Add additional lines N neenaaty.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Pneumonia
<br />disuse or condition resulting
<br />in death)
<br />fequautlally tW cesffitions.11
<br />any, leading to the cause IhWC:
<br />on line a.
<br />Einar the UNDERLYING CAUSE
<br />Idivaps er Injury mat initiated'
<br />the events raeuxinp.in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTETERVAt
<br />onset to death
<br />One Week
<br />18. PART 0. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Alzheimer` Dementia
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time pf death
<br />0 Net pregnant, btd ptagnant within 42 days of Wath
<br />❑ Nur Pregun4 tram pregnant 49 days 10 1 year before death
<br />❑ -Unknown H pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />❑ hdostrian
<br />other (Specify)
<br />18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES El NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, fans, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />OYES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23s. DATE OF DEATH (Mo., Day, Yr.)
<br />September 20, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />September 20. 2019 11:30 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to tin made) ®fated. (Signature and Thiel
<br />Gary Bettie. MD
<br />244. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the Weis of examination and/or imeetige len, In my opinion death seamen at
<br />the time, Ode and place and due to the eauu(e) stated. (Signature end Thio)
<br />25.ID TOBACCO USE CONTRIBUTE TO THE DEATH? glia. HAS ORGAN OR :nssua r e AT10N BEEN CONSIDERED?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN 0 YES /i e
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gary Settje, MD, 2116 W Feidiey #400, Box 9802, Grand Island, Nebraska, 88803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 215a Is NO 0 YES 0 NO
<br />28e, REGISTRARS SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mex, Day, Yr.)
<br />September 26, 2019
<br />0
<br />OD
<br />CXR
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