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<br />STATE OF NEBRASKA
<br />;.')ueRSt•pm sear;Off99iCCCC.�if�Rt$ a,rgyy,Vktu
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<br />x:tusiEtClifo , rr Awm.,.�
<br />WHEN mIS rag_ FY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, !T CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE f OPV OF 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 OPISS(UANCE
<br />5!312023
<br />LINCOLN, NEBRASKA
<br />202402014'
<br />SARAH BOHNENKA141(PT 7
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES`
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />RE CEDEN11 NAME (Elrst, Middle, Last, Suffix)
<br />Bouasvm
<br />c
<br />ERTIFICATE OF DEATH
<br />4. CITY AND STATE 1OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />and
<br />TI
<br />SOCIAL:SECURIT t NUMDER
<br />087044668
<br />Sb PACIUITY NAME Alfnot Institution, give street and number)
<br />OH! Health St. Francis
<br />8c CI1Y ISR TOWN OF DEATH (Include Zip Code)
<br />grand island 68803
<br />9a. RESIDENCE4TATE
<br />Nebraska
<br />fld.:STREET AND .NUMBER.
<br />1416WIStSt
<br />9b. COUNTY
<br />Hall
<br />5s.AGE - Last Birthday
<br />(Yrs.)
<br />74
<br />UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a PL 4CE OF DEATH :';:
<br />HOSPITAL I$3lnpadent
<br />0 ER/Outpatient
<br />O DOA
<br />10a. wutlTAE trxrus AT TIME OF DEATH ❑ Married 0 Never Married
<br />Married, but Separated 141 Widowed ❑ Divorced 0 Unknown
<br />FATHERS*I€AME '(IK
<br />!iia Ke ineth
<br />Middle,' Last, Suffix)
<br />13 EVER )N u*Aoggo,FORCE$? Give dates of service if Yes.
<br />(Yes, No, or unit.) NO
<br />15 METHOD OF DtSPOSITIoN
<br />QBu4a) ❑Donation
<br />J rematton': Qintombment
<br />❑'Remtnrai QOMarSifYi
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />HOURS
<br />MINS.
<br />17 05339
<br />3. DATE OF DEATH (MO:k Dsy,, YF;:
<br />Aprill4,°2017'. !.
<br />8. DATE OF elm (Mo., Day, Yr.)
<br />June 12, 1
<br />OTHER 0 Nursing Horne/LTC
<br />Decedent's Homs
<br />❑
<br />Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f ZIP CODE'
<br />68801
<br />gE. IN$IDi
<br />1:
<br />!0b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />Chanh Bouasym
<br />14a. INFORMANT -NAME
<br />Sue Bandasack
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12, MOTHER'SNAME (First, Middle, Maiden sume
<br />Keo Unknown
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />16b. LICENSE NO.
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town. State)
<br />14.1.Vittatoi.14Soildertilann Funeral Home, 601 N. Webb Road, Grand Island Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIQNStoe TO DEDEDENT'
<br />Daughter
<br />16c, DATE (M.. ,Dai, Yr.)
<br />Agri) 17
<br />CAUSE OF DEATH (SeeinatTufions and examples)
<br />it. PARTI. Enter ttlbeheM of tvanb- diseatq, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or stub icularfibfhation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Una. Add additional lines I necessary.
<br />IMMEDIATE CAUSE:
<br />a) Severe Left Middle Cerebral Artery ischemic Stroke
<br />Aifsi2 (FM4t
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />dltione,R 1)) Atrial Fibrillation
<br />cause Wes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />1
<br />events result
<br />LAST
<br />PAR
<br />in death)
<br />DUE TO, OR A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL,
<br />oneettodeath
<br />2 Data
<br />r
<br />I) OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not t'esul6ng n the underlying cause given In PART I.
<br />0. /F;FEMAL
<br />(lot prg4Mr
<br />Rragnald et'
<br />rt.pretpteitt;. but prat
<br />Nat pregnard,'but prig
<br />42 drys of death
<br />dela tot year before death
<br />nkobrnt O pragnani *Min
<br />INJURY AT WORK?
<br />O YES 0 NO.
<br />''TION OF INJU
<br />21a. MANNER OF DEATH
<br />® Neturel ❑ Homfpide
<br />❑ Accident ❑Pending Inveatigatinn
<br />❑ Suicide
<br />0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLAC
<br />RISE HOw INJURY OCCURRED
<br />STREET It NUMBER, APT.NO.
<br />RATE OF DEATH (Mo., Day, Y►.)
<br />April 14, 2017
<br />23b. DATE SKIED (Mo., Day, Yr.)
<br />Atoll 14; 2017
<br />OF INJURY -At
<br />CITY/TOW
<br />23e. TIME OF DEATH
<br />12:10 AM
<br />3ti•'iset of a knowledge, death occurred at the time, date and place
<br />&tld due td:hs chua(s) Stated. (signature and Ma)
<br />Douglas Herbek, MO
<br />S
<br />21:b. IF TRANSPORTATION INJURY
<br />.,, DWiter!Operator
<br />Paeeneer
<br />❑ Pedestria
<br />❑ Other (Specify)
<br />1S. WAS MEOIC.. L'EXAMINER
<br />OR CORONER CONTACTED?
<br />OYES NO
<br />21c. WAS AN Ai}TOPSY PEf
<br />❑ YES ND
<br />21d. WERE AUTOPSY NNW
<br />TO COMPLETE CAUSE OF D
<br />❑ YES ❑ NO
<br />tneifarm, sheet, factory, office building, const)
<br />BLE
<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 />tee. On the basis of examination andlor investigation. in my opinion death ee,pf3
<br />the ems data and place and due to the causes) stated (Signatwa endue)
<br />25 DID TOBACCO USE.CONTRIBUTE TO THE DEATH?
<br />[] YES El NO ❑ PROBABLY 0 UNKNOWN
<br />27 NAME, TIT#iAND ADI3R£SS OF CERTIFIER (Type or Print
<br />Douglas Herbek, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803`
<br />28a. HAS ORGAN OR TISSUE DONATION
<br />❑ YES ®NO
<br />REGISTRAR'S SIGNATURE
<br />BEEN CONSIDERED?
<br />26b. WAS CONSENTGRANTED?,
<br />Not Applicable if 26a is NO OYES 4 NI
<br />28b. DATE FILED BY REGIS'P
<br />April 25, 2017
<br />Day, Yr.)
<br />
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