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<br />WHEN ;i 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 OFISSLUANCE
<br />4/1/2021
<br />LINCOLN, NEBRASKA
<br />202207613
<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 />tECEDEN . S NAME (First,.. Middle,
<br />Florence Marie > Caspar
<br />Suffix)
<br />CERTIFICATE OF DEATH
<br />4 :CITY AND:5i ATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Emmett, Idaho
<br />7SOCAL'sapuerYNUMBER
<br />508-56.0330
<br />817: FACILITY4NAME>(If not institution, give street and number)
<br />E CHI Health 5t. Francis
<br />° 80, CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />Sa. RESIDENCE -STATE
<br />Nebraska
<br />SaAGE - Last Birthday
<br />(Yrs.)
<br />70
<br />Bb, UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Se. PLACE OP D£ATH
<br />HO$PITAi. ®Idtpatient
<br />❑ ER/Outpatient
<br />DOA
<br />HOURS
<br />MINS..:
<br />03778
<br />ATE Of DEATH(MQ, Doty Yr.);
<br />March 2.2020.................
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Novena
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify),
<br />Sb. COUNTY
<br />Hall
<br />+ 90T4EE1444D NUMBER
<br />4240 Lo rat Lane ;`
<br />10a MARITAVaTATU. AT TIME OF DEATH I 1 Married 0 Never Married
<br />iE
<br />0 Married;'but sopa "13 Widowed . ❑ Divorced 0 Unknown
<br />c
<br />11 FATt1£R'S-NAGE (First, Middle, Last, Suffix)
<br />Lucien Bottorf
<br />is, even IN U.S. ARN ED FORCES? Give dates of service if Yes.
<br />(Yes, No, Or-Unk.) NO
<br />15. METHOD. OF DISPOSITION
<br />Burial ❑Donation
<br />Cremator ❑ EntOttbment
<br />f Remov.i '.. ❑Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e, APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />lob. NAME OF SPOUSE (First, Middle, Last, ; Suffix) if
<br />Thomas 'J Caspar
<br />145. INFORMANT -NAME
<br />Thomas J Caspar
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hvronemus
<br />12. MOTHER'S -NAME (First, Middle,
<br />Viola McIntosh
<br />16b. LICENSE NO.
<br />1448
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a.:FUNERAL:11OME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />m
<br />CAUSE OF I)
<br />nstructloit
<br />CITY / TOWN
<br />Grand Island
<br />and exam
<br />e maiden
<br />Maiden Surname):
<br />INSIiCITYLIMIT'S
<br />YES ; NO
<br />14b. RELATIONSHIP TODEOEDENT
<br />Spouse'
<br />16c. DATE;4M0.,,Day, Yu)
<br />March x,.2020;:
<br />1*. PART I. Enter the chain of everts --diseases, injuries, or cotnplicatlons.hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />T IMMEDIATE CAUSE:
<br />es~,
<br />IMMEDIATE CASSE Mete a)End stage Chronic Obstructive Pulmonary Disease
<br />t)i4eaa* o condition (*Suiting
<br />[titbit/4h)
<br />Td'
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the chase listed
<br />on Mee
<br />E iartriaDNDER1030CAUSE 'C)
<br />(disease ar injury that fntflated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: •
<br />LAST _. d)..
<br />IS PART II OTHE
<br />Dementia
<br />SIGNIFIC
<br />STATE
<br />Nebraska
<br />17b Zip Code
<br />68$0.4
<br />APPROXIMATE INTERVAL
<br />onaretto
<br />Ch tnic
<br />NT CONDITIONS -Conditions contributing to the: leatb but not resuitin$i in tie unc
<br />20. iF FEMALE.
<br />C �' Net pregnant wINdn P01 ym
<br />❑, Pregnant dnie at dead'
<br />pregnant, but:pregnant within. 42 days of death
<br />0 0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown. Ifpragne t..watlNnthe past year
<br />E 22d. INJURY AT WORK?
<br />4 ❑ YES ❑ N..».
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not be detenntned
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ng cause given In PA
<br />21b. IF TRANSPORTATION INJURY
<br />❑ DdvertOperator
<br />❑ Passenger
<br />Pedestrian
<br />o Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />Ofi CORONER t ITACTED?
<br />❑ YES ®NO
<br />710. WAS AN AUTOPSY PERFORMED? .
<br />©YES 5iINO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES ❑ NO.::.>:
<br />tome, farm, street, factory, of ice building, done
<br />(Sp
<br />ATIOrJ;OF INJURY
<br />& NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.);,
<br />March 23, 2020
<br />23b. DATE SiGNED (Mo., Day, Yr.)
<br />March 25:.2020
<br />23d, Ta :the beatninty knowledge, death occurred at the timme, date and place
<br />and Moto Die causes) stated. (Signature and Task)
<br />Ryan D. Crouch, DO,
<br />23c. TIME OF DEATH
<br />02:20 PM
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24s, PRONOUNCED DEAD (Mo., Day, Yr.;
<br />24b. TIME OF DEATH
<br />E PRONOUNCED DEAD.'
<br />24*. On INS basis of examination and/or investigation, In my opinion deldik occurred at
<br />the time, date and place and due to the annals) stated. (Signature 00 TWO . '...
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />53 YES ❑ NO 0 PROBABLY 0 UNKNOWN
<br />it Milk TITLE /f,ND I DRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />28b. WAS NT Cit ?EDF .
<br />Not Applicable if 26a is NO `; ❑YES ❑ NO.
<br />28b. DATE f
<br />March 25, 2020
<br />BY
<br />(Mo.,
<br />Yr.) ;'
<br />
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