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WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEK R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />8/5/2003 20040845 <br />81ANLEY & COOPER <br />ASSISTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANDSUPPORT <br />08658 <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH ImaMM1 Day. <br />Margaret Ann Boroff <br />Female <br />July 29, 2003 <br />a. CITY AND STATE OF BIRTH lanorn U.S.A. narrw colaryl <br />Sa AGE -Lad Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />I S. DATE OF BIRTH /AkkwL Day. Ywl <br />Mos. t wvs <br />ScHOURS MINS. <br />Cedar Rapids, Iowa <br />IYraI 84 Sb <br />March 15, 1919 <br />7. SOCIAL SECURTIY NUMBER <br />9a. PLACE OF DEATH <br />507 -38 -7418 <br />Y2 - OTHER: Nurwg Herr <br />❑ <br />❑ ER Oulp40er6 ❑ P"Idence <br />6b. FACILITY - Name X np ouse OML 9rve aaeer and mmbad <br />St. Francis Medical Center <br />❑ ooh ❑ odrr/sp.adyr <br />Sc CITY. TOWN OR LOCATION OF DEATH <br />So. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yea ❑X Nd ❑ <br />Hall <br />I <br />91 . RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />. STREET AND NUMBER /Anck4iVZip CoWI 68803 <br />9e INSIDE CT' LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />r2O 24 N.lGnxId Islald Ave. <br />Yea ® No ❑ <br />10 RACE (e.g.. White. Black. Amer; an hdian. <br />11. ANCESTRY lo.g.. haMen. Mexicam German, etc) <br />12. O MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE IM w1de . g wmaiden namel <br />e1c.1 ISDeCnYI V&xite <br />ISOecdyl American <br />NEVER DIVORCED <br />MARRIED <br />1 Melvin L. Boroff <br />14a USUAL OCCUPATION 1Grw krrd or w * dprre dung mosf tab. <br />KIND OF BUSINESS INDUSTRY <br />1S. EDUCATION iSpecily orgy high" grade cornpleWl <br />d wwkngW even d'Wed) <br />Bookkeeper /Office Manager <br />Auto Parts <br />Ehnen or Secondary 10.121 Coder 11 .4 o. 5-I <br />1 <br />16 FATHER - NAME FIRST MIDDLE LAST 17 <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Ivan Roland 1 <br />Lucy Smile <br />16. WAS DECEASED <br />EVER IN U.S. ARMED FORCES? <br />19L INFORMANT -NAME <br />lvas. ro 0, touLl <br />10 yes. phi veer and Oars of servlceel <br />No <br />1 <br />Melvin Boroff <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN, STATE. ZIP) <br />2024 N. Grand Island Ave. Grand Island Nebraska 68803 <br />20 MSALMER - SIGNATUR4"4el�t O. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />#1071 <br />© su " . ❑ Re-wal <br />AuWst 1, 2003 1 <br />Wastlam Mmmr ial Patio C metexy <br />22a. FUNERAL HOME - NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />All Faiths Funeral Home <br />❑C'emse, ❑DWWW <br />Grand Island, Nebraska <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP( <br />2929 S. Locust St., Grand Island, Nebraska 68801 <br />23 I MME ATE CAUSE (ENTER ONLY ONE USE PER LINE FOR (a). Ibl. AND loll I InrrY" Der~ one" and oeam <br />PART <br />lal I <br />T OR AS A CONSEOU04CE OF I kaarval between 0.441 and death <br />I <br />(01 I I <br />E TO. ORQfS A CONSEQUENCE OF: I MWV" b"ween Or441 and oeam <br />I <br />(c1 <br />I <br />O E rfON . Cmdioar cpre0AN 10 er death but nd related PART <br />PART <br />IN IF FEMALE WAS THERE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />a <br />IN THE PAST 3 MON <br />EXAMINER OR CORONER' <br />IA9n <br />10.5x1 Yes No <br />Yea No X <br />Yea W �( <br />26. <br />26b. DATE OF INJURY /Mo.. Day. Yr./ <br />26c. HOUR OF INJURY <br />26Q DESCRIBE HOW INJURY OCCURRED <br />OACabanl Und«elm.W <br />M <br />Swcroe ❑ ParWeg <br />266. INJURY AT WORK <br />261. PLACE OF IW. Y -L11 , term, "reel factory <br />dhee bu11W1LL <br />24 LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Invealgabon <br />1,u ❑ No ❑ <br />27a. DATE OF DEATH /MO.. Day. Yr.) <br />26a. DATE SIGNED /MP.. Day. Yrl <br />26b. TIME OF DEATH <br />ag <br />July 29, 2003 <br />M <br />a <br />y <br />27b. DATE SIGNED /Ma. Day. Yr.l <br />27a TIME OF DEATH <br />2&. PRONOUNCED DEAD /Ma Day, Yrl <br />2Bd. PRONOUNCED DEAD /NOUI <br />July 30 03 <br />11:53 A.M <br />M <br />2 <br />27d. To I . Oe" of my k death occ ad "ate tk1» pace and dLw b the <br />26a. On She basis of exarmaach and,dr rrve"gabW n my opew dead, omwed at <br />causN61 stated. <br />6 <br />the Who. deb and Place and dw to ate ­m- III staled. <br />name and Tide ► - - <br />e x110 Thiel <br />29 DID TOBACCO USE CONTR TE THE DEATH? <br />a ORGAN OR TISSUE DONATION BEE CONSIDERED? 30b <br />WAS CONSENT GRTED? <br />AN <br />❑ YES ❑ UNKNOWN <br />❑ YES r NO <br />��J /// <br />❑ YES art.( NO <br />/� <br />31 NAME AND ADDRES F TIFIEA IPHYSIOUN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( /Type ate <br />John A. Wagoner M.D., 800 Alpha St., Grand Island, NE 68803 <br />32x. REGISTRAR <br />32b. DATE FILED BY REGISTRAR /AIa. Day. Yi/ <br />AR 4 2003 <br />I, Daniel Naranjo, do affirmUthat this is a true and accurate copy of <br />the death certi ate of Margaret Boroff. <br />r <br />- -- ��� <br />Dani aranjo <br />