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<br />WHEN THIS COPY CARRIES 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 DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />E`
<br />4/23/2026
<br />LINCOLN, NEBRASKA
<br />20260290
<br />g:N
<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 />CERTIFICATE OF DEATH
<br />0
<br />1
<br />g
<br />a
<br />a
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Ben LeRoy Buerger
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bassett, Nebraska
<br />T. SOCIAL SECURITY NUMBER
<br />508-38-3363
<br />8b. FACILITY -NAME (If not Institution, give street and nurhber)
<br />2405 Lakewood Drive
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />87
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />DOA
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH(Mc.,
<br />January 4, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 260933
<br />OTHER ❑ Nursing Home/LTC
<br />E Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />❑ Hospice Facility •
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREETANINUMBER
<br />2405 Lakekvood Drive
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First„ . Middle, Last, Suffix)
<br />Herman `Boer(1er!
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or link.) Yes 03/25/1953-03/24/1955
<br />15. METHOD OF>DISPOSITION
<br />Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />90.INSIDE CITY LIMITS.'
<br />® YES f NC
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Judith Lee Farber
<br />14a. INFORMANT -NAME
<br />Judith Lee Boerger
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Eunice Everingham
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Duff
<br />12a. FUNERAL HOAME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1071
<br />CITY / TOWN
<br />Rose
<br />CAUSE OF DEATH (See instructions and examples)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo, Day Yr.)
<br />January 11, Z .21
<br />111. PART I. Enter the chain of events- tilssases, Injuries, or compllcations4hat directly caused the death. DONOT 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 a line. Add additional lines a necessary.
<br />IMMEDIATE CAUSE:
<br />IMMI IATECAUstt (Final ..:: a) Vascular Dementia
<br />dlssete or aandltiOtl resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />sequenlalty nee conditions. ir. b) Cerebrovascular Disease
<br />any, leading to the cause listed:':.
<br />on Iln a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or Injury that initiated -
<br />theavents resulting in death)
<br />LAST.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART fl. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART 1.
<br />Atrial Fibrillation
<br />3e IF FEMALE:
<br />0 Not pregnant within pest year
<br />❑ Nragoont m om* of de*C
<br />❑ Not pregnant, but pregnant within 42 days oflleath
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown it pregnant within the past year
<br />22a. DATE OP INJURY (MD.Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES I 1+10
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />'STATE •
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Years
<br />onset to death
<br />Years
<br />onset to death
<br />onset to death
<br />19. WAS MEDICALEXAMINER''
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPL CAUSE OF DEATH?
<br />❑ YES NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc,:(speclfy)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY:' STREET & NUMBER, APT.NO. CITY/TOWN STATE
<br />P CODE
<br />23a. DATE OF DEATH (Mo., Diy, Yr.)
<br />January 4, 2021
<br />23b. DATE SIGNEO (Mo., Day, Yr.)
<br />January 7.2021
<br />23c. TIME OF DEATH
<br />09:53\PM
<br />tad, Tathe best et ray: knowledge, death occurred at the time, dib and place
<br />anddue totha causal') stated. (Signature and Thiel
<br />Travis S. Hageman, MD
<br />25.f DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />12.:YES . ❑ NO ❑.PROBABLY ❑ -UNKNOWN
<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 />2411. On the bails of examination and/or investigation, In my opinion death 0Caunsd of
<br />- the time, date and place and due to the cause(*) stated. (Signature and TINS)
<br />26a. HAS ORGAN OR TISSLIE DONATION ATION BEEN CONSIDERED?
<br />❑ YES 1 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraski,68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO OYES ❑ NO
<br />28b. DATE FILED BY REGISTRAR(Mo., Day, Yr.)
<br />January t2, 2021
<br />
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