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<br />WHEN THISCOPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />'HEA TRUE COPY OR THE ORIGINAL RECORD ON FILE WITH ME NEBRASKA DEPARTMENT OF -HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />202304433'
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH,"
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERWCES
<br />CERTIFICATEOF DEATH
<br />EDENT&NAME (First, " Middle, Last, Suffix)
<br />erDii)FMT :fie Boerkircher
<br />CI
<br />Cozad, Nebraska
<br />Ti
<br />OR FOREIGN COUNTRY OF BIRTH
<br />5a AGE Last SI titday Sb U
<br />(Yrs.)
<br />88
<br />R 1 YEAR
<br />2. SEX
<br />Female
<br />ac.
<br />3. DATE OP OEi3"
<br />►v
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />r S(aUTAE sEDURITYNUMBER
<br />-494220
<br />8b. FAcitiry-NAME (Rnot Institution, give street and number)
<br />eid:QuAiti#+ Care
<br />Sa.GITY oR Tpa
<br />Aurora 6881
<br />R
<br />C
<br />Nebraska
<br />DEATH (Include Zip Code)
<br />et snks'rANDIHUM. HER>
<br />11407 Weptt.oulse
<br />sur. PLACE OF DEA'l'f►
<br />HOSPITAL llpadsnt
<br />0 ER/Outpatient
<br />pD0A
<br />8b. COUNTY
<br />Hall
<br />19a AMARI'#AL STA l AT TIME OF DEATH ❑ Married 0 Never Married
<br />❑ Married, but separated ® Widowed, 0 Divorced 0 Unknown
<br />1.17:4T #TIBIAME
<br />Viroid Harry Gelken
<br />t, Suffix),
<br />CITYOR'TOWN Grand Island
<br />❑ s Home
<br />p Other (sp
<br />8d. COUNTY OF DEATH
<br />Hamilton
<br />8.a APT. NO.
<br />9f. ZIP CODE
<br />88801
<br />NAME OF SPOUSE (First,Middle. Lest, Suffix) if wile,
<br />Paul Erwin Boerkircher
<br />12 MOTHER`S. NAME (First, M
<br />Eleie . Mart'jerette Block
<br />13 'EVER IN U. ARMEE/ FORCES? Give dates of serf
<br />(Yep, No, or Unit,' NO
<br />15. METHOD OF DISPOSITION
<br />Burial•
<br />I=1c tttlslon
<br />OrematIon 0Entombmena
<br />❑ Removal < 0 Other (Specify)
<br />If Yes.
<br />14a. INFORMANT -NAME
<br />Colleen Maxon
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />14b.'
<br />1* LICENSE NO.
<br />tam
<br />Aucta
<br />18d. CEMETERY, CREMATORY OR OTHER LOCA
<br />Central Nebraska Cremation Services
<br />Ira FUNERAL HOME NAME AND MA)LINOADDRESS (Street, City or Town, State).:.
<br />,A)afe€ Furc al Home 1123 W. 2nd Grand Island, Nebraska
<br />CAUSE OF DEA.TH_'iSee netru aar a a examples)
<br />CITY r TOWN
<br />Gibbon
<br />is. PART L Enter the stein of events- -diseases, injuria, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />f
<br />Cutely arrest, mtvenhtcularfibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additlonetlhtes If napes
<br />IMMEDIATE CAUSE:
<br />a) Gallbladder mass felt to be cancer
<br />Sequentially list conditions, if b)
<br />any, leadbw to tire cause Hated
<br />TO, OR AS A CONSEQUENCE OF:
<br />TO, OR AS A CONSEGIUENCE OF:
<br />8.#CART: preptereeretcArtrCONDITIONS-Conditionscontributingtothedeathbutnot-`'
<br />hypertafilliots, Chronic kidney disease, hypothyroidism, atrial fibrilation
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />- Utranown i pregnantwithin are Past Year
<br />22a :DATE OF INJ Y(Mo Day,:Yr.)' 22b. TIME OF INJURY
<br />lid ate underlying cause given in PART I.
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Panting Inveetlgation
<br />❑ Suicide 0 Could not be detenum ed
<br />Ir
<br />MU R3f:' :STREET & NUMBER, APT.NO.
<br />OA rt~ OPC LATH (Mo., Day, Yr.)
<br />July 28, 2023
<br />CITY/TOWN'
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />July 1, 2 04:16 PM
<br />Ztd. la the best crow knowledge, death occurred at the time, date and place
<br />and;due tolhe Cause(s) stated. (Signature and Title)
<br />Jane McDonald, MD
<br />TE SIGNED (Mo.,
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.), 24d.
<br />DID TOBACC O USE CONTRIBUTE TO THE DEATH? i 28a. HAS ORGAN OR TISSUE • •ATI
<br />ME, nita;ANE
<br />McDone
<br />. PROBABLY ❑ UNKNOWN I 0 YES 'El
<br />AD» OF CERTIFIER (Type or Print)
<br />l MD, 800 N Alpha St, Grand Island, Nebraska,'68803
<br />28a. REGISTRAR'S SIGNATURE
<br />BEEN C
<br />CI `fit. WAS CO
<br />Applicable N28ele
<br />28b. DATE FILED BY
<br />August 1, 2023
<br />..,'Day,. Yr.) "L .
<br />
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