|
Anal , %rEbint l
<br />gtt t'°r r Cts Y,t'44
<br />6g �."@ ' 't('.� 11 i I I . If 141
<br />9 � s F' lir I'I 1 1 a� ! i.IEddll� tLit riI„d„(,srht �a€�Z 111a.1t d43a uraas.lr,d,,, Y(s
<br />pt��d(�h�iNwa(COI�I�II�,�dd�rPA1A( � I/tdfe.nm�tr .1 �„ :RAti � ,taA�...l„ tdd . „PiN �GMAruuap\
<br />,. .....::'.. ... .. `.:.. .:.I ('TATO At• \II�rrhA[5VA �. ..'
<br />�azt$1Ir�91119ffA?E,„ x+ R11444'Aliv 'at/t11'11Y'(1TIINr.° 9r�tntmnlr a�
<br />'a ft to 1 3000Aur° Q�p
<br />Yj Y) ar 3.:ta'IiS7m 47Ai
<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 f
<br />DATE OFISSUANCE RUSSELL FOSLER
<br />1/14/2019 202005599 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 />LINCOLN, NEBRASKA
<br />igd lV V1) P
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Shirley Ann Boguslaw
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 8, 2019
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />85
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo.,Day,Yr.)
<br />September 22,1933
<br />7. SOCIAL SECJRITY NUMBER
<br />507.'4.-6.,01
<br />8b. FACILITY -:"WE ()f not'lnsttueon, give street and number)
<br />419 Holcomb St
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑Inp.'ant
<br />0 ER/Outpafient
<br />❑ DOA
<br />OTHEi' 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />r' Ht spice Facilit•:
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />419 Holcomb St
<br />9b. COUNTY
<br />Hall
<br />8d. COUNTY OF DEATH
<br />Hall
<br />So. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS"
<br />® YES ❑ NO
<br />lea. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />Leonard Michael BOquslaw Sr
<br />12. MOTHER'S -NAME (First, Middle,
<br />William Edward Schleichardt Ethel Dorothy Meyers
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />14a. INFORMANT -NAME
<br />Leonard Michael Boguslaw
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF -DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />January 11, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery
<br />17a. FUNERAL NOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b. ZIp Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1s. PART I. Enter the shein or events. -diseases, injuries, or compikations-that directly caused the death. DO NOT enter terminal' scants such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one ause.da a line. Add additional lines if necessary.
<br />Ip IMMEDIATE CAUSE (Final
<br />E disease or condition resulting
<br />c
<br />22d. INJURYATWORK9
<br />L] YES LJ NO
<br />M.
<br />a 22f. LOCATION OF INJURY STREET 8, NUMBER, APT.NO.
<br />N
<br />O
<br />In death)
<br />Sequentially Pat tpndhWna, If
<br />any, leading le Na cause Ilsted
<br />Enter the UNDERLYING CAUSE
<br />(disease -or -44m that Inittles/I
<br />the events resulting in death)
<br />LAST'
<br />a) Respiratory Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Congestive Heart Failure
<br />APPROXIMATEINTERVAL
<br />•
<br />2 Days
<br />onset to death
<br />3 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />onset to
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Chronic Obstructive Pulmonary Disease
<br />20. IF FEMALE:
<br />0 NM Pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Net prefnam but Preenent within 42 days of death
<br />© Not pregnstd, but
<br />pregnant 43 days to 1 year before death
<br />❑ IAnknosm it ptgtnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />Other telmelfy)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY:: FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES No
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />TE OF DEATH "ao., Cay, 'Ir.)
<br />J.inuary 8, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Janua 1. 211•
<br />CITYITOWN
<br />STATE
<br />;Ina. DA't $13NE J (Mo., Da), ...) 24b. TIME OF DEATH
<br />1111
<br />g
<br />g
<br />O. To the test of my knowledge, death occurred at the time, date and place
<br />and due to the casuist stated (Signature and Title)
<br />aac J. Berq, MD
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<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 causes) stated. (Signature and Tice)
<br />25. Die TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO ❑ PROBABLY 0 UNKNOWN 0 YES ® NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339 Grand Island, Nebraska, 68803
<br />28a
<br />REGISTRAR'S
<br />SIGNATURE .lr J
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mc.,;Day, Yr.)
<br />January 10, 201901
<br />
|