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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE E NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DAT . CIF`.!SS. UAN E
<br />2/9120 a'
<br />LINCOLN, NEBRASKA
<br />20220238
<br />r 664 47,444
<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 />1. DECEDENT'S -NAME (fiirst, Middle, Last, Suffix)
<br />PEU141.e .Kay Bodes
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7• SOC(AL SECIIRITY.NUMN:BER
<br />.5.06,60.;7608
<br />8b. FACILITY -NAME ftff otInstitution, give street and number)
<br />CHI. Health. St.. Francis
<br />8c :.CITY OR TOWN 01 DEATH (Include Zip Code)
<br />Grand]Sland 6x803
<br />9a. RESIDENCE -STATE •
<br />Nebraska.
<br />9d.:STREET AND NUMBE:R..
<br />•745 Pleasantview;Drive
<br />10a::MARITAL STATUS AT TIME OF DEATH ® Married
<br />0 Married,' but separated 'Q Widowed 0 Divorced
<br />•11:FATHERS`NAME.(First,• Middle, Last, Suffix)
<br />9b. COUNTY
<br />Hall
<br />0 Never Married
<br />0 Unknown
<br />William Lorarlce; .
<br />13. EVER IN U S ARMFp.I ORCES? Give dates of service if Yes.
<br />(Yee, No, or Uhk.) No • • .
<br />15. METHOD OF DISPOSITION •
<br />1 Burfa] ❑ Dons*ion
<br />J.CreMatiO#40.Entonibment
<br />kiiiiIoval ❑Othei'(Specify)
<br />5a. AGE - Last.Birthday.
<br />(Yrs.)
<br />Sb.'.UN[YER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba, PLACE OF:DEATH
<br />HOSPITAL E Inpatient
<br />❑ ER/Ou patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />22 01655
<br />3. DATE OF DEATH:(Mo., pay �'r,
<br />January 2C2022
<br />6. DATE OF BIRTH!(Mo., Day; Yr:j
<br />December5, 1::941
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Hospice. Fa.Cillty;"..
<br />9g.1 IN IDE CITY LIMITS'
<br />Ipd SES ❑ ;[VO
<br />105. NAME.OFSPOUSE (First, Middle, Last, Suffix) If wife, give maiden name '
<br />Garry Wayne Bolles
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />12. MOTHER'SNAME (First, Middle, Malden Surname)
<br />Juila Swartz
<br />14a. INFORMANT -NAME
<br />Garry Wayne Bolles
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, Stats)
<br />All FOiths Fw'(eral I-(pme, 2929 S. Locust Street, Grand Island,; Nebraska
<br />CAUSE OF DEATH (See:..iinstructlons acrd examples)
<br />14b. RELATIONSHIP TO,DECEDENT'
<br />Spouse
<br />16c. DATE (11:1.10 7.
<br />January 36 2Q22
<br />8.. PART 1. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal evems such as cardiac arrest,
<br />•. • respiratory. arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMM9DIATt?9AI5&(Plee! a).septic.shock and cardiogenic shock
<br />disease or Lonurnen reeUItinit ,
<br />Sequentially list conditions, if
<br />any,,IesQing to tt,e;caase:.iiated
<br />on ti116 a
<br />Enterthe UNDEt(YING GtUSE
<br />(disa80B crinjury that.hitiated
<br />the events resulting; in death) •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) heart failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) atrial fibrillation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PART-I.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting an the underlying cause given in PART I.
<br />20.
<br />Not•pregnaht.10)1810 pastyear
<br />Pregnant at hale of dead -
<br />Not ptagnant but pregnant within 42 days of death
<br />❑ Not pregnant,: but pregnant 43 days to 1 year before death
<br />Unmown iimegnagt.withIn the past.year
<br />2a :GATE OF INJURY (MO Day, Yr:)
<br />22d. INJURY AT WORK?
<br />DYES❑NQ,.:..
<br />22f, I QCAT1oN t%F IN-IURy STREET & NUMBER, APT.NO.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />2113, IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />•
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other(Specify)
<br />STATE
<br />. • Nebraska
<br />97b Zip Code,:;
<br />fr88ff1
<br />APPROXIMATE INTERVAL
<br />onset to'death
<br />Days_ .
<br />onset to death
<br />Months
<br />onsAttoideath
<br />onset to death
<br />19, WAS MEDICALEX4MINER;;
<br />OR CORONER.0ONTACTED?
<br />❑ Yes ... 1 NO
<br />21c. WAS AN AUTOPSY PERFORMED.? . >.:
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVA09I.E
<br />TO COMPLETE CAUSE OF DEATH?
<br />• ❑ YES ❑ NO ,.,
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction site, 8tc fS:pec(fy)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23e. DATE OF' DEATH (Mo., Day, Yr.)
<br />January 28, 2022
<br />cirYIrOvdl
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />January 28;.2022 10:05 AM
<br />Sd TAthe bast of myknowledge, death occurred at the time, date and place
<br />and. due 10188Iause(s) stated, (Signature and Title)
<br />The Wut Yee, MD
<br />25, DID:TOBAGO0 USE CONTRIBUTE TO THE DEATH?
<br />YES:;Q NO Q PROBABLY ® UNKNOWN
<br />27 NAME TITLEAND ADDRESS OF CERTIFIER (Type or Print
<br />The Wut Yee, MO, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR
<br />❑ YESEl
<br />ISSUE DO
<br />No
<br />28a. REGISTRAR'S SIGNATURE
<br />STATE 2;iP CQDE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD,.
<br />24e. i3rt the basis of examination and/or investiga Ion, in my opinion death ee4rret#.at.(
<br />the time; date and place and due to the cause(s) stated. (Signature and Tide)
<br />ATION>:BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED? ..
<br />Not Applicable if 26a is NO ❑ YES ❑ No
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 7, 2022 •
<br />Ot>
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