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<br />STATE OF NEBRASKA
<br />A rrrr , ,I I 7r)
<br />rllr,„11a0 /rl/fll1�IT111iN,.�. rrr.yr0. rr711111N11D63x� -, rrrux " rrQ7�Il1�t111N5 rrrrr „r� r%/l1'I�Illllilrll� ` r rlrni, l;1i111111i,"j;
<br />WHEN tHIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRtiECORYOF'TNE 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 />:DA 7 OF ISSUANCE'
<br />/ 5/19/2026
<br />LINCOLN, NEBRASKA
<br />202603581
<br />,36t4di ghttitak44
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE'OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANSERVICES
<br />CERTIFICATE OF DEATH
<br />1 DECEDENTS4IAME (Fire*,: Middle, Last, Suffix)
<br />Velda Rae Boelts`
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Neodest. S .Kansas
<br />r SOCIAL BECUHITYNBMBER
<br />513=484014
<br />tea. AGE - Last Birthday
<br />(Yes.)
<br />81
<br />Sb. FACILITY-HAIM Sr not institution, give street and number)
<br />Grand Islan Regional Medical Center
<br />8t:. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand island: 68803
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9b.000NTY
<br />Hall
<br />9d, STREET AkND:NUMBER s;
<br />416;p. ArthurSt
<br />10a. MARITAL STATUS AT TIME OF DEATH 10 Mauled 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />FATHERS.NAMME (Flit,
<br />Theron Johnson::"
<br />Middle, Last, Suffix)
<br />•13. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or;Unk.) No
<br />1I1.METHOD OF DISPOSrflON
<br />❑ Burial Donation
<br />ljcorne8on:; iEtopmbment
<br />❑ Removal 0 Other (Specify)
<br />bb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />bc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL DE inpatient
<br />0 ER/OutpatIent
<br />❑DOA
<br />9e. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH lAO,. Day Yr )
<br />May 8, 2026 .::.;
<br />S. DATE OF BIRTH (Mo., Day, Yr.)
<br />Apr1114, 1
<br />OTHER 0 Nursing Home/LTC 1 . ill spin Fat Sty
<br />❑ Decedent's Home
<br />❑ Other (Speclfy)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />N. APT. NO.
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Dale
<br />Boelts
<br />12. MOTHER'S -NAME (First,
<br />Bernice McKinney
<br />14a. INFORMANT -NAME
<br />Dale Boelts
<br />lee. FUNERAL DIRECTOR SIGNATURE
<br />Kelley D Sheridan
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />4Ta FUN•ERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Alt s FaithFuneral H•omer 2929 S. Locust Street, Grand Island, Nebraska
<br />tab. LICENSE NO.
<br />/ 1439
<br />M. ZIP CODE
<br />68803
<br />Suffix) If wife, blve maiden name
<br />Middle, Malden Surname)
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See Instructions and examples)
<br />1e. PART I. earth* chain of events- diseases, Mimi's, or compllcd ationstet directly causedterminal
<br />the death. DO NOT enter events such as cardiac arrest,
<br />meMMaMry anent, or vet kuUi tlbdeaaon without showing the stioloay. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines W necessary.
<br />CAUSE:
<br />atlt�IATEr.d usspig,d a) Ischemic colitis
<br />;:dtseaait:br aar•
<br />itwislliisuNinp
<br />In death)
<br />§,9001t illy eat cocAdrp lr.: ,..
<br />ally ts +g t the f Ye hated
<br />dsi Nns M:
<br />fJ Enterthis up/Destro/a. cAusti'
<br />'5 (disease or (spry that initiated
<br />the events moulting indeath)
<br />WT
<br />I
<br />et
<br />14b. RELATIONSHIP TO DECEDENT
<br />_ r
<br />1Sc, Pan (M0 Day, Yes)
<br />May 11, 2028.: STATE
<br />.Nebraska
<br />1744/0C4ida
<br />68801
<br />APPrATE INTERVAL
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />0)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />'111. PART IL OTHER SIGNIFICANT CONDITIONSCond tIons contributing to the death but not resulting In the underlying cause given In P
<br />Coronary artery disease, hypertension, malnutrition
<br />20::IFFEMALE:
<br />war j 1ee91le tw:11*1pestywr;i
<br />© ►nprrefii; et terra* death >..
<br />print ❑ Not pre, but pregnant sithln 42 days of death
<br />❑ul❑ Not pregnant, but pregnant 43 days to 1 year betels death
<br />tI mdWn lfprepastgrlant edthln tilt year
<br />224. DAME OP N4JIIRY I'MOr.Ioy, Yr.)
<br />32d. INJURY AT WORK?
<br />OYES.❑N°
<br />21a. MANNER OF DEATH
<br />Ea Natural ❑ HomIcide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />-❑ Dttver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Met (specly)
<br />onset to death
<br />onset to
<br />onset3odeaal
<br />ART I.
<br />19. WAS MEDICAL' EXAMINER..
<br />OR CORONER CONTACTED?
<br />OYES :.; MA„
<br />21c. WAS AN AUTOPSY PERT,
<br />❑ ?Es , j No
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ Nit
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, Sic. (I
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF 'MOH STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 2026
<br />23b, DATE SIGNED (Into., Day, Yr.) 23c. TIME OF DEATH
<br />MaY •11l 2024 12:40 PM
<br />i234. ?outs MK of my kailmiedge, death occurred at the time, date and place
<br />'and died to the taunts) stated. (signature and Tots)
<br />Chad Vieth, MD
<br />'OBACCO IiSECONTRIBUTE TO THE DEATH?
<br />ESQNOO [ PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DO
<br />❑ YES El NO
<br />STATE
<br />2N. DATE SIGNED (Mo., Day, Yr.)
<br />24e, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF
<br />24d. TIME
<br />me: bin the been of examination and/or Investigation, iri ny opinion dMg► ttglidfld N
<br />the time, date and place and due to the cause(s) stated. (Signature end Tale)
<br />7ION BEEN CONSIDERED?
<br />NAME1 T tE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Feldlpy #400, Box 9802, Grand Island, Nebraska, 68803
<br />C-
<br />2eb. WAS CONSENT GRANTED?
<br />Not Applicable B 28a le NO DYES::
<br />28b. DATE FILED BY RE
<br />May 14, 2026
<br />
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