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<br />STATE OF NEBRASKA
<br />�24117r11IP11i�� ,' Irlr�gr,�fft� + :3411'IIIf1Nt�� '
<br />EA1411EA/i Thilf,SV COPY CARRIES THE RAISED SEAL 'OF THE STATE OF NEBRASKA, '
<br />CERTIRES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,.
<br />. "RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY.FOR VITAL RECQ.R. DS
<br />PATEO lts.s miCE 2 n 2 •
<br />V O U 7 3 1
<br />1/15/2021 • 4
<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 />LINCOLNr NEBRASKA
<br />CERTIFICATE OF DEATH
<br />'i. DEEGEDENTSNAME;(First, Middle, Last, Suffix)
<br />Ben:: I.eRE y::: Boei er
<br />4. CITY AND STATE OR:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bassett, Nebraska
<br />7 SOCIALSECURITYNUM;BER
<br />5(18 38 3363
<br />8b. FACILJTY=NAME;If trot Institution, give street and number)
<br />2405 Lakewood Drive
<br />Sc CITY OR TOWN OFDEATH (Include Zip Code)
<br />Grand island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d,:STREE7ANONUMBER..
<br />2405 Lakewood Drive
<br />9b. COUNTY
<br />Hall
<br />10a: MARITAL ETATI . AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />11. FATHER StNAME :(First, Middle, Last, Suffix)
<br />Herman Baerger
<br />13 EVERIN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 03/25/1953-03/24/1955
<br />15. METHOD OF DISPOSITION
<br />i ;Burial ❑ DonStion
<br />❑ Crematan ❑ Entorisbment
<br />Removal ❑Other (Specify)
<br />Se.: AGE - Last Birthday,
<br />(Yrs.)
<br />87
<br />Sb,.UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF'DEATH
<br />.HOSPITAL ❑ Inpetlent
<br />•❑ `ER/outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />21 00239
<br />3. DATE OF D "ta f t* r., Ow, Yr..)
<br />January 4' 2021
<br />FQbrua
<br />OTHER 0 NwNng Ho
<br />geoedant's Hopis
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />qe. APT. NO.
<br />91. ZIP CODE
<br />68801
<br />lOb. NAME.OF SPOUSE (Orst,• Middle, Last, Suffix) if wife, g1v+
<br />Judith Lee Farber
<br />12. MOTHER'S-NAME (First, Middle,
<br />Eunice Everingham
<br />14a. INFORMANT -NAME
<br />Judith Lee Boerger
<br />RTH (Mo., bay,'Yf'z)
<br />28, 1:#133 .,...
<br />co. Miley
<br />Ifis 4E:r VAR4ITs ::
<br />® YES ❑ CIO >:
<br />*den
<br />1:4b RELATIONSHIP
<br />)ECEDENT:
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Duff
<br />18b. LICENSE NO.
<br />1.071
<br />CITY f TOWN
<br />Rose
<br />'16c. DATE.(Mo., Day, Yr.)
<br />.January 11 2D21
<br />•
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />loll Faiths Funeral:Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See lnstructionsand examolAet)
<br />....
<br />,a. PAR'r'i. Ewa tlKCMrri or events- Weems, injuries, or eomprlcatrons3hat directly caused the Beath. DO NOT enter terminal swan sucfi ae 27kdrao ennui,
<br />respiratory arrest, or ventricular /Methadon without showing the etiology. DO NOT ABBREVIATE. Enter only one cans one line. Add additional lines If nueseary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Vascular Dementia
<br />dineitise or tendll'an. reaching > .. ..
<br />In eleath):::
<br />Sequentially list conditions, If
<br />any, leading to the caupa listed
<br />Enter the UNDE,ILYINO
<br />miiitillaterinaifittooffiiiitteed
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Cerebrovascular Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 ;PART fi' :OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but nottesuttln
<br />Atr'1aI PibrilkOn
<br />20. IF FEMALE:
<br />filet prgna within
<br />i Dart year
<br />pregnant M ites of death:
<br />❑;:Nit pregnitt but pntynent within 42 days of death
<br />❑ Not pregnant, but pregnant4a days to el yaer before death
<br />:. 0 Unknown if pregnant „thin the past year
<br />224DATE OF)N,)URY(MAo; Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Rending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />n the underlying cause given in PART I.
<br />21rb^.�.IF TRANSPORTATION INJURY
<br />:.L„ i Ogre/Operator
<br />.;❑ Paeenger
<br />❑pedestrian
<br />❑ Other (Specify)
<br />.17b. Zip.: Cade
<br />oneU
<br />Years
<br />It
<br />I ILAE EXAMINER'
<br />CONTACTED?
<br />NO .....
<br />21c. WAS AN AUTOPSY PE
<br />0 YES'. El NO
<br />21d. WERE AUTOPSY FINDINGS AVAIt.AB E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ Yes ©NO ,
<br />22c. PLACE OF INJURY -At horns, farm;' street, factory, office building, cone
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATioN;OF INJURY STREET& NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />23a. DATE 'OF"DEATH (Mo., Day, Yr.)
<br />January 4, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />January7.2021 09:53 PM
<br />To thk best of imy knowIadgs, death occurred at the time, date and place
<br />*data to the>Cttuss(s) stated. (Signature and Title)
<br />Travis S. Hagman, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES :❑ NO '❑ PROBABLY 0 UNKNOWN
<br />27.NAME, TITIL AND ADDRESS OF CERTIFIER (Type or Print
<br />a
<br />as
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />DEATH ..
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr4
<br />ti& kmaishai a of examination andbr hweledgetlon,
<br />the tkt ,' dab and place and des to the paUee(*) stated.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES iia NO
<br />' r is $<Hagei'I'ien, MD, 729 North Custer Avenue, Grand Island, Nebraska 68803'
<br />28a. REGISTRAR'S SIGNATURE
<br />tab. WAS CONSENT GRANT
<br />Not Ap?lloable H 26e Is NO
<br />NCED DEAD
<br />28b. DATE FILED eVREGISTRAR (Mo., Day, Yet)
<br />January 12, 2021
<br />
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