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<br />WHENTHIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE=A' TRUE COPY: OF THE ORIGINL RECORD ON FILE WITH THE NEBRASKI ° DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE; WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />.B
<br />tp".
<br />a
<br />DATE OP ISSUANCE
<br />1/2/2026 <`
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS-M,Al1s7tFirs :. Middle, Last, Suffix)
<br />Judith: >Lee;":Bo rger
<br />4. CnY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ainsworth. Nebraska
<br />Ts SOCIAL fSECURI . NUMB Rt
<br />507':42-957
<br />SARAH ROHNENKA
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />7-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE: OF DEATH
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />85.:•• •..
<br />Sb, FACILITY -NAME (if not institution, give street and number)
<br />CHI Health StFrancis -
<br />do Cii7f' R:TOWN<OF DEA.3M:;flnclude Zip Cam)
<br />Grand island <68803'
<br />ea. RESIDENCE -STATE
<br />>:NebraskaT
<br />Otte STREET ANC, t&UMBER''
<br />2405..Lakewtaod
<br />9b. COUNTY
<br />Hall
<br />Oa. MARITAL STATUS AT -TIME OF DEATH 0 Married 0 Never Married
<br />© Married, but separated ® Widowed ❑ Divorced 0 Unknown
<br />11 FATHER!$ -NAME (First,"' : Middle, Last, Suffix)
<br />John Virrwjii:; Farber :. Jr --
<br />13, EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or Unk.) No
<br />It MET OD.OF DISPO$ c..N.
<br />j ]Burial 13 Donation
<br />E Cremation El Entombment
<br />0 Removal ❑ Other (Specify)
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS•
<br />DAYS
<br />ea. PLACE; OP DEATH :. .
<br />HOSPITAL EJ: InpriUpnt
<br />0 ERlOutpatlent
<br />( Poll::
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />OTHER 0 Nursing Homed.
<br />Decedent's Hoar
<br />❑ Other(Speotty)
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE 1,68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give mad
<br />14a. INFORMANT -NAME
<br />Carole Urbom
<br />tea. P,)NERAL DIRECTOR SIGNATUR
<br />Kelley D Sheridan
<br />42. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Vema Mary. BratthaU r
<br />15d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Duff Cemetery
<br />1,T,::a: FUNERAit. HQNEE NAMEAND MAILING ADDRESS (Street, City or Town, State)
<br /><Ail Faith 'Funieral:`Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />`'lab. LICENSE NO.
<br />• 1439
<br />CITY I TOWN
<br />Rose
<br />CAUSE OF DEATH(See instructions and examples)
<br />14. PART I. Enter the chain of events- diseases, Injuries, or compllcetlona4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />... mapkwicty arrest, or veatdculer fibrillation without showing the etiology. DO NOT ABBREVIATE; Enter only one cause on a ttne, Add additional lines If necessary.
<br /><.::IMMEDiATE CAUSE:
<br />;'; ; MEO TE ommai (ia. < :'*) vascular dementia
<br />*swear atat1NfIonr1Nuitine
<br />in death)
<br />Sequentially list conQidons,if
<br />any; leading tothe rase bided.
<br />tier line;
<br />.':t nt r nil UNDERLVING CAUSE
<br />(disease or Injury that initiated
<br />the events resulting In death)
<br />LAST ..
<br />Dl(E TO, OR AS A CONSEQUENCE OF:
<br />b)diabetes
<br />DUE TO, OR AS A DONSEQUENCE OF:
<br />)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />7
<br />ill. PARTS. 211ON1F'tOANT.CONDITIONE-Conditions contributing to the dbath but nut..fdtiulthrg in
<br />diabetes, congestive heart failure
<br />20.IF FEMALE:
<br />Not pr55iwi t wit In p1st y r
<br />Q Pragnant at'ti na'ni
<br />0 Not POP/lank Out MOOTS within 42 days of death
<br />© NM Pregnant, but mignint43 days to 1 year before death
<br />Q; unitr cWn p-pripnam vrltliiii:eu pact Year
<br />sm. DATE
<br />NJ
<br />(Mc., bay, Yr.)
<br />22d. INJURY AT WORK?
<br />(]go
<br />LOCAdT ON..OF INJURY
<br />21a. MANNER OF DEATH:::.
<br />® Natural 0 HomItide
<br />Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />i
<br />underlying cause given in PART I.
<br />21b. IF TIMSPORTATION INJURY
<br />Dnwr/operetor
<br />D Passenger
<br />0 Pedeatnan
<br />O Other (Specify)
<br />22c. PLACE OFINJURY-At tiorfte.ferm
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />SET & NUMBER APT.NO. CITYROWN
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />December 15, 2025
<br />:23bi:DATF.tiiGNED;(Mo., Day, Yr.) 23c. TIME OF DEATH
<br />, `Decer>;tber 17 2025 06'45 AM
<br />:S3d: To,t a Mist offiiy (tnowledge, death occurred at the time, date and place
<br />. "ind,dut totha:aiute(e) stated. (Signature and The)
<br />Travis S. Hageman, MD /
<br />nuto.DD0
<br />IE:C9N1;1BUTE TO THE DEATH?
<br />'YES:: Np ;;" PROBABLY 0 UNKNOWN
<br />NAM1E, TM E R AD .;::. S OF CERTIFIER (Type or Print
<br />Travis S. Ha 9sman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAt#;;OR
<br />❑ YES
<br />14b. RELATIONS 11;S
<br />Daughter
<br />111c, DATE (Mo., l
<br />Decerrlbe
<br />1
<br />21c. WAS"AN AU
<br />D YES
<br />tF
<br />21d.: WERE"AUTOPi1''FNIOIINQSAVAILANLS-
<br />TO COMPUTE CAUSE:OP SEATNT'
<br />©vas Qari
<br />eeet factory, office building, conatruetio
<br />STATE
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />.240.PRUNCED DEAD (Mo., Day, Yr.)
<br />24e, 0n thS balis.of examination and/or investigetloe, In my opinion
<br />'the thite, date and place and die to the camas) stated, islprMs
<br />SSUE t ATION BEEN CONSIDERED?
<br />i7 NO
<br />26b. WAS CONSENT GRAN
<br />Not Applicable N Eli is NO-
<br />25b. DATE FILE
<br />December 22, 20
<br />
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