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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 />4/16/2020
<br />LINCOLN, NEBRASKA
<br />202009020
<br />.),(44411 84--/L4/74d,
<br />SARAH BOHNENKAMP
<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 />i1, DECEDENTS -NAME (Fksi, Middle, Last, Suffix?
<br />Delta Mae Joan Boltz
<br />�4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Merrick County, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-72-4800
<br />• 8b. FACILITY -NAME (If not Institution, give street and number)
<br />as
<br />E 2112 West Charles.
<br />et
<br />80. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island', 68803
<br />✓ 9a. RESIDENCE -STATE
<br />Nebraska
<br />ad. STREET AND NUMBER
<br />2112 West Charles
<br />9b. COUNTY
<br />Hall
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />1 10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />co0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />88
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6e. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatlent
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 04595
<br />3. DATE OF DEATH(Mo., bay, Yr.}
<br />April 7, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 17, 1932
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />❑Hospice FacUNty
<br />9g. INSIDE CITY LIMITS
<br />YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Gene Allen Boltz
<br />e 11. FATHER'S -NAME (Fkat, Middle,
<br />s William Wichmann
<br />Last,
<br />Suffix)
<br />112. MOTHER'S -NAME (First,
<br />Edna Bader
<br />Middle, Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />G (Yes, No, or link.) No
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />E Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />3
<br />14a. INFORMANT -NAME
<br />Gene Alien Boltz
<br />14b. RELATIONSHIP: TO DECEDENT
<br />Husband
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16e. DATE (Mo., Day, Yr.)
<br />April 9, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Ali Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />§18. PART 1. Enter the chain of events- -diseases, Injuries, or complications.hat directly caused the death. DO NOT entertenninal events such as cardiac arrest,
<br />respiratory arrest, or ventrlcular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />7aa IMMEDIATE CAUSE Vont a) Undetermined Natural Causes
<br />e. disease or condition resulting
<br />N= In death)' -
<br />to
<br />v
<br />2
<br />O
<br />Sequentially list conditions, N
<br />any, lending to the cause listed
<br />on lines.
<br />Enter the UNDERLYING CAUSE.
<br />(diseaseOr Injury that Initiated
<br />w 1 the events resulting in death)
<br />ns
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />onset to death
<br />19. WAS MEDICAL: EXAMINER
<br />OR CORONERCONTACTED?
<br />❑ YES NO
<br />0. IF FEMALE:
<br />0 No pragnantwithin pail year
<br />0 Pregnant at lime: o1 death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />O 0 Unknown N pregnant within the part year
<br />yY 22a. DATE41
<br />F INJURY (Mo., Day, Yr.)
<br />21e. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?.
<br />❑ YES ENO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />O YES 0 NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc.
<br />(SPY)
<br />I 22d. INJURY AT WORK?
<br />T3 ❑ YES 0 N
<br />e
<br />a 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />23d. To tete best of my knowledge, death occurred at the time, date and place
<br />and due to the amount!) slated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY E UNKNOWN
<br />v
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />April 9, 2020 Approx. 10:00 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />April 7, 2020 10:27 AM
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred et
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Dave Medlin, Hall County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E NO
<br />127. NAME, TITLEANDADDRESS OF CERTIFIER (Type or Print
<br />Dave Medlin, Hall County Attomey, 231 S. Locust, Grand Island, Nebraska, 68801
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable N 26a Is NO 0 YES
<br />NO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />April 13, 2020
<br />
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