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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CIDS THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DpOSITORYFOR VITAL RECORDS
<br />B
<br />DATE OF I$$UANCE;
<br />1216/2025'` .
<br />LINCOLN, NEBRASKA
<br />1:. DECEDEN *NA6115 ;(Finn Middle, Last, Suffix)
<br />Larry 1J rom Bolles
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />;Grattid Island ,Nebraska
<br />X:;so000. 040uMly NONNER
<br />508.42 3286
<br />202602�25'
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF pEATK
<br />5a. AGE - Last Birthday
<br />(Vrs.)
<br />87
<br />6b FACIUTY-NAME (It not institution, give street and number)
<br />Veterans Affairs. Medical Center
<br />1)ci CIiYOR tOVi N OF DEATH4Indud• Zip Cods)
<br />Grand.lslar d: e8603
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />6a. PLACE OF DEATH
<br />HOSPITAL finInpltffsnt
<br />❑ ER/Outpatient
<br />DOA.
<br />HOURS
<br />MINS.
<br />2515815
<br />3. DATE OP W? $Mo.,'bay, V r)
<br />November 21' R 25 ,
<br />6. DATE OF BIRTH (
<br />May 20,193:.,
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Oth.r N)
<br />sd. COUNTY OF DEATH
<br />Hall
<br />, Day, Vr.)
<br />H04044 F•440M
<br />as. RESIDENCE -STATE
<br />ad4nt iaTANDNUMIERt
<br />3304 Buffalo Court ; :
<br />6b.000NTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married 0 Never Monied
<br />❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown
<br />11. FATHERS -NAME (First,...; Middle, Last, Suffix)
<br />Francis Horner Bolles
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or Unk.) Yes
<br />i4:.4METHOD.OF Di8POElTI014
<br />J final ji'lmetion
<br />❑ Cremation 'Qlntawnt
<br />❑ Removal ❑ Other (Specify)
<br />10b. NA
<br />9c. CITY OR TOWN
<br />Grand Island.
<br />the. APT. NO.
<br />6f. ZIP CODE
<br />68803
<br />dig. (NOIDE CCf 1t LMtr€$
<br />ME OF SPOUSE (First, Middle, Last, Suffix) If wile, give maiden name
<br />14a. INFORMANT -NAME
<br />Denise Zabka
<br />15a. FUNERAL DIRECTOR SIGNATURE
<br />Bailee J McAtee
<br />12. MOTHEWS.NAME (First, Middle, Mabel(Sumams)
<br />Alice N .OooleY
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a FUNERAL HOME NAME MO MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home 1123 W. 2nd, Grand Island, Nebraska
<br />1lb. UCENSE NO.
<br />1604
<br />CITY/TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See Instructions and examples)
<br />14b. RELATIONBNIP TO DECEDENT
<br />Daughter
<br />14c. DATE (Mo.;!`ki y,_' r«)
<br />December 1 2054. .
<br />STATE
<br />Nebraska
<br />111. PART 1. Enter the cheln of *Vente- dN.Has, Injuries, or connpBeations4hat d6,cty caused the death. DO NOT enter termite& events such u cardtec arrest,
<br />.,rsegratory arraR or veaplcuter fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one um. on altos. Add additional lines a n.cs.wry.
<br />IMMEDIATE CAUSE:
<br />1tONSS,iTECAU$EiFhlal e)alzheimers Disease
<br />4eaeari at' don4114.0 r.4i411n
<br />/ a.athl DOE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Set conditions+:If b)
<br />Soy. leading ip the orauze IMMO
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter Bear tN DERLYING CAUSE" C)
<br />(disease or Is um that Initiated
<br />the eves resulting In duds) DUE TO, OR AS A CONSEQUENCE OF:
<br />tsar .,,...d)
<br />IS. PARTS, OTH$11SIGNIFI.`ANTCONDITIONS-Condltlons contributing to the death but not/moulting In thevntl.dying cause given In PART 1.
<br />*to F FEMAt,$•
<br />Not P srtnt 0.4i, y�Ar
<br />'❑ 1..gnaea.td.0 et'dwtih
<br />❑ Not pregnant, but pregnant Wilda 42 days a,Maah
<br />❑ Not pregnant, but pregnant 43 days to 1 year berm death
<br />uniiii.4Aitp44.444iiit. past year
<br />Ze. DATE OFINJUAY (Mon, bey, Yr.)
<br />APPROXIMATE INTERVAL
<br />onset tB Ell t :..'.
<br />5 Years
<br />onset to
<br />4 onset to (N6ath
<br />16. WAS MEDICAL EDIAMINEfi .
<br />OR CORONER CONTACTED?'
<br />❑ YES IE NO
<br />21a. MANNER OF DEATH
<br />RI Natural 0 Notnklde ..
<br />❑ Accident 0 Pending Imeadgatimr
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22d. INJURY AT WORK?
<br />Ylt.S pixo
<br />. LOCATION OF INJURY,; STREET & NUMBER, APT.NO.
<br />21b. IF TRANSPORTATION INJURY
<br />© Driver/Operator
<br />[1 Plineenaor
<br />❑ Pedestrian
<br />.❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFO*MNI,
<br />CI YES glNO
<br />21d. WERE AUTOPSY FINOING$ AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />/ ❑YES ❑NO
<br />22c. PLACE OF INJURY -At home, faint street, factory, office building, construction sits, etc. girt')•
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />CITY/TOWN STATE
<br />aSlk DID
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 21, 2025
<br />23b DATE$K#NED4Mo., Day, Yr.)
<br />t*Itefnber 232025
<br />23c. TIME OF DEATH
<br />07:40 PM
<br />22d. fertile &Mat of sty Ktsarrtedge, death occurradat the tine, date and place
<br />nhd Mato the eweap) sealed pignehne andlnla)
<br />Catherine M. Eberle, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />Ddc, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRON00401WPFAD
<br />2/9On 6k bears or examination and/or inva.dgation, In pry uplubn dygl eltdlleed st
<br />-tat time, date and place and dui to the cauea(s) seated. (6isnstte ad Tide)
<br />TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR DONATION N BEEN CONSIDERED?
<br />YES NO 0#PROBABLY ❑ UNKNOWN 0 YES _
<br />ME, BB. ND ADDRESS OF CERTIFIER (Type or print
<br />xia NO
<br />. tl: 11
<br />Catherine M. Eberle, MD, 4101 Woolworth Ave, Omaha, Nebraska,68105
<br />26a REGISTRAR'S SIGNATURE
<br />� k t
<br />26b. WAS CONSENT GRANTED#.:
<br />Not Applicable H 26a is NO [, Y
<br />20b. DATE FILED BY REGISTRAR (Otis,
<br />November 24, 2025
<br />0
<br />01
<br />
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