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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 BELO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, V7TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISSUAN'
<br />1015/2023
<br />LINCOLN, NEBRASKA;
<br />202401948
<br />34V1
<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 />'1 DEOEDENV$ NAME 4F rat, Middle, Last, Suffix)
<br />Anna Jean Boersen
<br />CERTIFICATE OF DEATH
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Doniphan, Nebraska
<br />7 SOCIAL SEDIONITY NUMBER
<br />505 44 2788
<br />5a. ABE • Last Birthday
<br />(Yrs.)
<br />Sb.`FACILITYNAME{If Sot Institution, give street and number)
<br />Bryan Medical Center West
<br />8c CITY OR TOWN OF'DEATH (Include Zip Code)
<br />L ncoln 68502 .
<br />8a. RESIDENCE STATE
<br />Nebraska
<br />9d. STREET At4b NUMBER
<br />222 5out)f:;0ak
<br />9b. COUNTY
<br />Hall
<br />Sb UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />ea. PLACE OFDEATN
<br />HOSPITAL ©Inpatient OTHER 0 Nursing Home/LTC
<br />• ❑ ER/Outpatient 0 Decedent's Home
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Ma, Day, Yt )'
<br />September 21; 2023 .
<br />6. DATE OF BIRTH (Mo., Day*;
<br />October 6,.193.7
<br />0 DOA
<br />105. MARITAL*TAWS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated E Widowed 0 Divorced 0 Unknown
<br />11 FATH£R S'NAME (First, Middle, Last, Suffix)
<br />Harry ('titter
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD ❑
<br />OF DISPOSITION
<br />ilu- Dol anion
<br />0ther(Specih/)
<br />❑
<br />Cremation Entombment
<br />Removal
<br />9c. CITY OR TOWN
<br />Grand Island
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />8jp INSlITiECITYLfM1TS':
<br />Nam
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give midden name
<br />Earl Boersen
<br />14a. INFORMANT.NAME
<br />Jimmy Boersen
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12 IitOTHERS NAME (First, Middle, Maiden Surname
<br />Wilda; Krueger
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />17a. FUNERALHOME NAME AND MAILING ADDRESS (Street, City or Town, :State)
<br />tayinDSt004OrklEtroann Funeral Home, 601 N. Webb Road.ii,Gtatictis(a
<br />1Bb. LICENSE NO.
<br />rid, Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (S [n01401005 and exampled
<br />14b. RELATIONSHIP TO DECEDENT,
<br />Son.
<br />18c. DATE (Ma,
<br />September 26, 2423
<br />16. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. 00 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 aline. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />witimoi Tscause (Pure) ? a) Chronic Obstructive Pulmonary Disease
<br />disease or conditionPandang
<br />in down
<br />Sequentially list conditions, N
<br />any,: leading to the cause listed
<br />itiNDEtN'.YHNG CAUSE
<br />(ditiatBent in)uf!:that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />Is PART 5.OThER IDNIEICANT CONDITIONS -Conditions contributing to the death but net re
<br />atrial•flbtillatlon ..
<br />20. IF FEMALES:
<br />Nat Pregnant wtariapastyear
<br />CI
<br />: Pregnant et.t the Of deaat
<br />Net pregmint, but pragthint within 42 days of death
<br />0 Na pregnant, but pregnant 43 days to 1 year before death
<br />❑.. Unknown If. pregnant withinth past year
<br />22d, ;DATE OF INJURY;Mit:, Day, Yr.)
<br />22d. INJURY AT WORK?''
<br />❑YES 'ONO
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ pending Investigation
<br />❑ Suicide ❑ Could not ba determined
<br />22b. TIME OF INJURY
<br />lung
<br />(TATE
<br />Nebraska
<br />$7b. ZJp Code
<br />88883'
<br />In the underlying cause given in PART I.
<br />21b.;IF TRANSPORTATION INJURY
<br />gli.Difirar/Operator
<br />Passenger
<br />f❑ Pedestrian
<br />❑ Other (Specify)
<br />18, WAS MEDICAL EXAMINER:
<br />OR CORONERCtN1TACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES E No
<br />21d WERE AUTOPSYPI:NDIN
<br />TO COMPLETE CAUSE OF
<br />❑YES ONO
<br />22c. PLACE OF INJURY At hothe ; farm, street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22F LOCATION OFINJURY STREET& NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 21, 2023
<br />CITY/TOWNi'
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />§001err her 26. 2023 03:35 PM
<br />To the (hast of my knowledge, death occurred at the time, date end place
<br />atfd due tethit tause(a) stated. (Signature and Title)
<br />Jeffrey E. Jarrett, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES NO .: l PROBABLY ❑ UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME;;
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the its of examination andlor Investigation, in my opbtion death occurred at
<br />the tkns, date and place and due to the cause(s) stated. (Sipnaturd and Title)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />21.:NAME, T)TLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jeffrey E. Jarrett, MD, 1500 South 48th Street, Suite 800, Lincoln, Nebraska, 6
<br />28a, REGISTRAR'S SIGNATURE
<br />06
<br />2Eb. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO DYES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 26, 2023
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