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<br />STATE OF NEBRASKA
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<br />VHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OP THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN` SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF?SSUAKCE
<br />LINC(JLN, NEBRASKA j,
<br />202204086
<br />a
<br />SARAH BOHNENKAMP. f
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />f OSOsoali $AIME (First, Middle, Last, Suffix)
<br />Donald .:Lee .Boeka
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />Et7CIAL SECURtrrNuM
<br />505-54-3798
<br />BER
<br />5a. AGE - Last eirthday'
<br />(Yrs.)
<br />8b. AMITY -NAME Of not Institution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />Scfc.QTTY.Off. TOWN OF DEATH (include Zip Code)
<br />Glertd I$laltd 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />78
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />Ba, PLACE OF:DEATI4
<br />HOSPITAL ❑ Inpatient
<br />ERIOu patient
<br />DOA
<br />DAYS
<br />HOURS
<br />MINS.
<br />•
<br />zz 06282
<br />3. DATE OF DEATH.(Mo. Day Yr
<br />April 23; 2(122
<br />6. DATE OF BIRTH (Mo.; DayYi
<br />March 16, 1;944: , ;:
<br />OTHER ® Nursing Home.LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />9d STREET A1V0 NUMBER
<br />1.8121W t.oUl3e Staet
<br />16a. MM. ITAL.ETATUB AT TIME OF DEATH Married 0 Never Married
<br />Married, but separated []Widowed 0 Divorced 0 Unknown
<br />Middle, Last Sutfix)
<br />11.1?Iti11ERS NAME {
<br />Narmart ;':ISoeka,;;
<br />13:#01414 .Eit.IN U*. ARMEDF FORCES? Give dates of service if Yes.
<br />or un.,tt,) Yes 0#26/196740/26/1,971:
<br />16. METHOD OF DISPOSITION
<br />,j Burial fl Donatt on
<br />Cremation f ento»t bment
<br />❑Rettutval ❑ Other .(Specify)
<br />l0* NAME OF SPOUSE (First, Middle, Last, Suffix) If
<br />Patty Brown
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9s. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />14a. INFORMANT-HAI/1E
<br />Patty Boeka
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />INSItl crr.....AM
<br />® D
<br />12. MOTHER'S••NAME (First, Middle, Maiden Surname)
<br />NOtniti Affatchelder
<br />16b. LICENSE NO.
<br />1537
<br />14b. RELATIONSHIP TO (381£(EtE Ni
<br />Spou
<br />16c. DATE (Mo., Day, yr.) s.
<br />April 28''
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17k!MgRAL Ht tME NAW€ AND MA LING ADDRESS$ (Street, City orTown, State)
<br />Aptel Funeral l4a e, 1123 W 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See
<br />Inetructlpns.and examples)
<br />18. PART I Enter theehaln of events- -dIseittiell, Injures, or comp lcationa hat directly caused the death. DO NOT enter terminal events such as algae arrest,
<br />respiratory arrest, or vefrtrkuiaf fibrlation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a ane. Add additional lines ti necessary.
<br />IMMEDIATE CAUSE:
<br />a4t tRAT41 Alt tfhoaE a) Parkinson's
<br />disease or #SnditOft reauhhig:
<br />in death}
<br />sequentially list conditions, If:
<br />. iny; leedhrg•to the cause gated
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />8rtie'ttae uNrrtf(#'IG tSAtl69
<br />(disease erinfufythatlM6ated
<br />the Lrents resulting:In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C).
<br />DUE TO' OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART H,.:OT3ER SIGNIFICANT CONDITIONS -Conditions contributing to the -death
<br />Hypertemion, Oiabt t;il, Seizurp,Disorder, Dementia, Bladder Cancer
<br />20 IEREMALE•
<br />Not pregnent:wttidn pastyeaf
<br />Pregntdd at gma of death
<br />Not pregnenf; but pregnant vAggn 42 days of death
<br />❑ Not pregnant, but pregnant 424fitinttoRlear before death
<br />ry Unknown Hpregnentwithin the pant year
<br />22SC ATE+DF tNSIit
<br />tY (Mc Day, Yr.
<br />22d. INJURY AT WORK?'
<br />YES ;,
<br />21a. MANNER OF DEATH
<br />Natural ❑ Hamtldde
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />d notresttltiagIn theunderlying cause given in PART 1.
<br />19. W.
<br />MErs4;EatAMMI5R;: i
<br />.--
<br />Tkopol
<br />22b. TIME OF INJURY
<br />22c. PLACE OF
<br />22e DESCRIBE HOW INJURY OCCURRED
<br />22k: CAT'ONOF It1,IURY-STREET 8 NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Apnl232022
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />ADrII 27.2022 '
<br />21rb�. IF TRANSPORTATION INJURY
<br />LJ Driver/Operator
<br />❑ Pasenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />0 yes
<br />21c. WAS AN All7
<br />0 YES
<br />YPERFOfti
<br />21d. WERE AUTOPSY FINDINGS AVAILABI E
<br />TO COMPLETE CAUSE oF DEATH?
<br />❑ YES ❑ .NO ..
<br />URY.At home, farm, street, factory, office building, construction e
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />10:25 AM
<br />add Tom* hsstetmey retowledge,death occurred at the time, date and place
<br />eti:d due la ,lie louse(,) Stated, (Signature and Title)
<br />Chad Vieth, MD
<br />2S DID TQBACCO USECONTRIBUTE TO THE DEATH?
<br />YES N} i, PROBABLY UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />. On the treads of eseminauon and/or investigation, in my opinion Assent aoStt+red of
<br />thtime, date and place. and due to the cause(s) stated, (Signature and
<br />eT
<br />le).
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />11f l hM T Ti
<br />YES NO
<br />AND ADi REBS OF CERTIFIER (Type or Print ❑
<br />Chad Uat)1, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28e. REGISTRAR'S SIGNATURE e ,
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO YE3
<br />28b. DATE FILED BY REGISTRAR
<br />May 5, 2022
<br />Mo., Day, Yr.)
<br />
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