|
'iddliltllilrm,„aa,,O11/Y111) o
<br />STATE OF NEBRASKA
<br />Iirl(,,,,mua��i1111{tlltlll%ii i� , : ,1i�11,1,llilrrt�,ii.J]
<br />a1tt7:ff1.P.1't165a
<br />WHEN mils COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA,. IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA !DEPARTMENT OF HEALTH AND
<br />SERVICES, 1/ITAL. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORYFOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />8/412023
<br />LINCOLN, NEBRASKA
<br />202
<br />SARAR B
<br />ASSISTANT STATE REGISTRA**
<br />DEPARTMENT OF HEALTH /
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE' OF DEATH
<br />DE ENDS.NAME;First, Middle, Last, Suffix)
<br />Carot)t Marie, Boerkircher
<br />4 CITY AND STATE OR7ERRITORY, OR FOREIGN COUNTR'
<br />? CIALSECURITY NUM BER
<br />C8-4#4220
<br />5a. AGE Last
<br />(Yrs.)
<br />8b. P ACILiiY-NAME (If rtot Inntitudon, give street and number)
<br />VVestfleld Quality Care
<br />c$..OR TC
<br />rora EE
<br />Nebraska
<br />N OF 13 T (8utlude Zip Code)
<br />TA
<br />Ed. 83'REETAND HUMBER
<br />:
<br />1407 Westtouise.Street
<br />Bb. COUNTY
<br />Hall
<br />10at llfARiTAi:SrATU&ATTIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />i1 f?Ait1ER'SNAAMR iFlrat,
<br />VErgIi Harr Geiken
<br />13 EVER IN U:& ARMED
<br />(Yes, No, or Unk) No
<br />ddle, Last, Suffix)
<br />RCES? Sive dates of seMce K Yes.
<br />16. METHOD OF DISPOSITION
<br />• ❑ a rias ) Donation
<br />Cremation ] Entontbmont
<br />Removal ❑Other(Speciiy)
<br />ii
<br />day :db UNDER 1 YEAR
<br />MOS.
<br />ea, PLACE OF:DEATH
<br />HOSPITAL 0 Inpatient OTHER ® Nursing Hom<C
<br />❑ ER/Outpatient 0 Decedent's Home
<br />DAYS
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF
<br />JuIv 24, 2023
<br />6. DATE OF MAW (Mo..
<br />0 Other (Spectfy)
<br />18d. COUNTY OF DEATH
<br />Hamilton
<br />De. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Sulittr)lf w
<br />Paul Erwin Boerkircher
<br />12. MGTHER'S+NAME (First, " Middle,' M
<br />Else Marearette Block
<br />14a INFORMANT NAME
<br />Colleen Maxon
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION;'
<br />Central Nebraska Cremation Services
<br />yrs. FUNERAL Honig NAME AND MAILING ADDRESS (Street, City or Town, State);, .
<br />Ai l EUnetel Home 1123 W. 2nd, Grand Island, NebraskpA.
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />ghat maiden name
<br />.r.
<br />14b TIONSt
<br />;Dauahjar
<br />inc. DATE (Mo.,
<br />AlJu
<br />CAUSE OF DEATH>1See 1nstructtons Mild examples)
<br />10. PART I. Enter 140 chain of events- diseases, InJurles, or complcaeons that directly caused the death. DO NOT entertemitnsl events such as cardiac arrest,
<br />riratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary..::
<br />IMMEDIATE CAUSE:
<br />a) Gallbladder mass felt to be cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially 1101 conditions. If b).,...
<br />any.leadag to the caws Sated;
<br />nit BM'e
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Es** UNDBRL INO GAUSS D)
<br />(listless Or Injury: hat rniti'atad:
<br />the events "'"'king in death) DUE TO, OR ASA CONSEQUENCE OF:
<br />(Aar d)
<br />go
<br />18' PART 11 OVIER SIGNIFICANT CONDITIONS -Conditions contributing to the dna
<br />hyparlertnioni.chronio kidney disease, hypothyroidism, atrial fibrilation
<br />20. IF FEMALE;
<br />ci Rtotprsonton40atfapaltyRer
<br />Pregnantat041efdaatlh :.
<br />02202priigrinithbut pnpryeutbt within 42 days of death
<br />❑,.Not pregnant, but pregnan44s days to 1 year before death
<br />©'=unknown d pregnant wi hin the pastyeer
<br />224N11617Fil DIff (Mo> Day,1%)
<br />22d. INJURY ATWORK?
<br />❑ YES 0 NO.
<br />RT)
<br />22e.
<br />21a. MANNER OF DEATH
<br />. NaWrel 1:111 orm ids
<br />❑ Accident ❑ Pending kaSieaEiod
<br />❑ suicide 0 Coed nottrwbe deteiinined.
<br />not resultil g intihsttnderlying causOgiven
<br />22b. TIME OF INJURY
<br />IESCRIBE
<br />PART I.
<br />21bb IF TRANSPORTATION INJURY
<br />Ori iootterator
<br />C passengst
<br />Peasstdah
<br />❑ Other ISPeeiry)
<br />21d. WONAUT AtiAl#J
<br />TO COMPLY OAUSEQF DEATH?
<br />22c. PLACE (ii INJURY M home, faun, street, factory, office building, construction
<br />HOW INJURY OCCURRED
<br />a8T
<br />ER, APT.NO.
<br />STATE
<br />23a. DATE OF DEATH (Mo., Day, Yr.),
<br />July 28, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 31i29;3
<br />3d 'ro the beat afaly knowledge, death occurred at the)time, date and pace
<br />and dna 10 tiro c lusa(s) sratod. (Sign hreand TltIe)
<br />~ m Mane McDonald, MD.
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />LI
<br />23c. TIME OF DEATH
<br />04;16 PM
<br />24a. TATE SIGNED (Mo. Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TMgt OF DEATH
<br />24d. TIME
<br />Cn 'bait of examination andtar investigating. ISM 20110424d ib occw
<br />1li0Ikse.Vdate and place and due to the causes) aid. Nitottlkint ands.
<br />26a. HAS ORGAN DR TISSUE 001441
<br />0 PROBABLY 0 UNKNOWN 0 YES iJ NO
<br />Ni ME, T1 �:t4 .Ot ESS OF CERTIFIER (Type or Print) ,
<br />Jane MoDOnald., MD, 800 N Alpha St, Grand Island, Nebraska; 68803 s
<br />BEEN CONSIDERED?
<br />26b. WAS
<br />Not Applicable If Zea Is NO
<br />28a. REGISTRAR'S SIGNATURE
<br />2
<br />Day, Yr.)
<br />
|