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a WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE �ANLEY S "COOPER JUL 3 1 200o 200502551 ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH 1 t DECEDENT . NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH 44v1rh Dat yearn •"" Lavern Robert Bonsack July 7, 2000 a. CITY AND STATE OF BIRTH IN nd r USA. name Country) Sa AGE • Last Birthday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIRTH iMpnM. Dav Yearl Shelton, Nebraska (Y's I 7 Sb -M DAYS k. HOURS' -INS I 11/11/1925 7 SOCIAL SECURTIY NUMBER Be. PLACE OF DEATH 506-22-3901 HOSPITAL, 71 InoatiBnl OTHER L] Nursing Home 8b FACILITY -Name (Nnor,rnse(uepn, give street and numoer) ❑ ER Outpatient ❑ A"ido -Ce St, Francis Medical Center ❑ DOA ❑ Oner(Sodcav! Sc CITY TOWN OR LOCATION OF DEATH fftl INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island I yes n No 11 Hall 9a. RESIDENCE • STATE 9b COUNTY 9c, CITY, TOWN OR LOCATION 90 . STREET ANO NUMBER "m" 1 ge INSIDE CITY LIMITS Nebraska Hall Wood. River' 15662 W. Stol Pik Yes El NO [� 10. RACE - le.g., While, BlaCk. American Ind-an. 11. ANCESTRY (e.g.. Balian. Mexican, German. elcl 12. ® MARRIED ❑ WIOOWED 13 NAME OF SPOUSE Pr wile. give maiden namel etc.I(Soec'm white ISpedlhr) American 12MAaRIED___ F] NEVER DIVORCED Bernice E. Conn Ida. USUAL OCCUPATION !Grua kind d work dorei dinning mp51 14b. KIND OF BUSINESS INDUSTRY 15, EDUCATION ISoec,ty only "Ighosl grade completed) of wwxing Me even if ropled) Elementary or Secondarv10. 121 College I4s • Retired Farming 12 i 16. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Henry Bonsack Agnes Frank 1 18. WAS DECEASED EVER IN U.S- ARMED FORCES? Iga INFORMANT "NAME IYeWUr unk,l 111 yea. give war And cities of servlce5l IVLL.11 Bernice Bonsack 19b. INFORMANT MAILING ADDRESS (STREET OR R.F 0 NO., CITY OR TOWN, STATE. ZIPI 15662 )W Stolley Park Road Wood River, NE 68883 ;2a. 8 ;OE ATURE 8 O 21 a. METHOD OF DISPOSITION 21b. DATE 21 <. CEMETERY OR CREMATORY NAME Burial ❑ Removal July 10, 200 Cameron Cemete _ FUNE • NAM 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Ap E1 Funeral Home ❑Crematia ❑ponanon North of Wood River, NE 221b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP) P.O. Box 126 Wood River, Nebraska 68883 23. IMMEDIATE GA BE (ENTER ONLY ONE CAUSE PER LINE FOR lal, lot. AND ICI( I Interval between onset and deal" PART ' e r c b r o v 4 5 C:e t i 4 r Q cC -cJe� -� � /fo c e -rs lal � OUE T OR AS A CONSEQUENCE OF Interval between onsat and death (b) �e r e bro V,:? c U (c. r V ausc -'_� DUE TO. OR AS A CONSEOUENCE OF r Interval between onset and deals S }cc fz�r5 ; ee dCMi1�C �7 {r�taJS o �C. c rl OTHER SIGNIFICANT CONDITIONS • Conditions Contributing to the death du not related PART pl I EMALE. WAS THERE A 2 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL PART . /� /Y �% PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONERS II • �4 I� �` r 'u� / • ,y t/ /J r4 / (Ages 10•Sd) yes NO Yes NO Yes N. 26a / 'f 1 1 L-25b DATE OF IN RY`- (M/o.'. Day. Yr.1 2Y8c CHOUR`OF INJURY, 28d. DESCRIBE HOW INJURY OCCURRED - - '- Accident Undetermined .. - ...... M Suicide Pending 26e. INJURY AT WpRK 26T PLq ;F OF INJURY - At V. (arm, 51roet. factory 28g. LOCATION STREET OR A.F.D. N0- CITY OR TOWN ,STATE.'. O IBceC budding, Ole (SAVO Homicide Investigation vas ❑ No ❑ 27a. DATE OF DEATH jhb.. Day. yN 28a. DATE SIGNED (Mo.. Day. Yr 1 28b TIME OF DEATH . 27b. DATE SIGNED (Ma. Day. YO 27c. TIME OF DEATH 28c. PRONOUNCED DEAD (Alp.. Day Y I : _ 26tl. PRONOUNCED DEAD /Noun gig �7 o . m .... 3 1 .. M a rr ... , Sur M .. S ° 27tl. To Ih0 best of my k edge. our at the .dale and place and due to the $ 2Be. On ma basis Of examination and or mvesUgaapn, m my opinion death occurred at - ~ Caueelal stated ate time. data and place and due to file causeN stated. IS nature and Tide " S name and T-10 - 29. DID TOSACC0 USE CONTRIS E DEAT 30.a HAS ORD R TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED( - .. . YES ❑ NO ❑ UNKNOWN 1:1 YES ® NO YES NO ❑ 31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type Cr -0 ai Gtr d # rand 1SL-;Lqd ALF 32b. DATE PILED BY REGISTRAR (Alp., Day. Yr,) :�. 32a. REGISTRAR trU JUL 2 0 2000 . . I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE FILED WITH THE BUREAU OF VITAL STATISTICS IN LINCOLN, NEBRASKA. 1 APF$L-BUTLER-GEDDES FUNERAL HOME