200505651 - Laserfiche WebLink

Browse

t STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD.ONF-ILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICE'S SYSTEM, VITAL STATISTIC &MCT /f2N IA+H S THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAY 0 '� 20V T 4fLEY St_COOP MF SATE REEIC S LINCOLN, NEBRASKA 2 005 0iI 65 1 HHEALTH ANDJUMAN SERVICES STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOR o O 4 S 6 2 CERTIFICATE OF DEATH I�JJ _ 1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX 3, DATE OF DEATH (Mo., Day, Yr.) Norman nick Henry.B.osselman Male April 18, 2005 4. CITY AND STATE OH TERRITORY, OR FOREIGN COUNTRY OF BIRTH 3e. AGC -Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) MO9. OAVS �OU RS M IN5. Worms, Nebraska' 89 Sept. 19, 1915 ea. PLACE OF ... ........ .. -- !, 7. SOCIAL SECURITY NUMBER DEATH 506-46-1401 HLISEITAL: ❑ Inpatient MER: QQ Nursing Home /LTC U Hospice Facility "0911'J'. 8b. FACILI'IY -NAME ( no institution, g It t ititutionive street and number) U ERlOulpatlent Q Decedent's Home Tiffany Square Center Cl 7Q4 ❑ other (speclfy) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH errand Island 68803 all 9a. RESIDENCE•STATE 9b, COUNTY 9c. CITY OR TOWN Nebraska all Grand Island - - 9d. STREET AND NUMBER 9e. APT.Np 9f. ZIP CODE 3103 Brentwood Circle 68801 Ice. MARITAL STATUS AT TIME OF DEATH ] Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) It wife, give maiden name. 9g. INSIDE CITY LIMITS 9 YES ❑ NO Married, but separated ❑ Widowed U Dlvorced ❑ Unknown Annetta Kuck 11. FATHER'S -NAME (First, Middle, Last, Suffix) 11, MOTHER'S•NAME (First, Middle, Maiden Surname) Charles Bosselman Johanna Von 'Aschenbeck -- 13. EVER IN U.S. ARMED FORCES? Give dates of 11,1111, it yes. 14s.INFORMANT -NAME 14b. RELATIONSHIP TO DECEDENT (Yes,no,orunk.) Yes 2-11 42/10-4-431 Annetta Bosselman Wife - 15. MEMTurOD OF DISPOSITION U Donation 161,. MBALMER- SIrG -AT RE - -- - 161b3 C2EN8SE N0. - 1604-22-2005'' 1. ( ❑Cremation UEntombmenl 18d. CEMEfiERY ,CREMAT�YOROTHERLOCATION CITY /TOWN STATE ❑Removal U Other (Specify) Nebraska Zion Lutheran Church Worms 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code All Faiths Funeral Home 2929 S. Locust St. Grand Island, E 68801 18. PART I. Enter the qh alo j. ovela- -diseases, injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE I respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add WItional lines It necessary. I IMMEDIATE CAUSE (Final IMMEDIATE CAUSE: � (a) w�� --'' Onset to death - - -•. � I V `•� I disease or condition resulting -... G _. _.- pUETO,OR SACONSEOUEN EOF: - ea onset to death In death) Sequentially list conditions, ll any, leading to the cause listed (b) DUE TO, ORCONSEQUENCEO I _ onset to death on line a. rn ......... .....__ ......... ___E -1 y 23b.DATESONEb(Mo. ay,Yr.) 23o.TIMEOFDEATH_� Enterthe UNDERLYING CAUSE 24c.PRONOu NCEDDEAD(Mo.,Day,Yc) 24d.TIMEPRONpUNCEDDEAD aa� E -- 4:19 Pm (disease or Injury that Initialed (o) the events resulting In death) pUE T0, OR AS A CONSEQUENCE OF: I onset to death LAST 24e. On the basis of examination and /or investigation, In my opinion death occurred at the,time, dale and place and due to the cause(s) stated. (Signature and Title ) T and due to the causes st ed. (Signature and cm r1, 00 rrtU `o I 18 PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ❑ NO 20. IF FEMALE! 21 MA R OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? afural ❑ Homicide ❑ Driver /Operator ID Not pregnant within past year U YES t JO ❑Passenger ❑ Pregnant at time of death ❑ Accident(.] Pending Investigation ❑ Not pregnant, but pregnant within 42 days of death U Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO P 9 ❑Suicide ❑Could not be determined U Not pregnant, but pregnant 43 days to i year before death J Other (Specify) COMPLETE CAUSE OF DEATH? ❑ Unknown if pregnant within the past year ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.)� 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d.INJURYATWORK' 22e. DESCRIBE HOW INJURY OCCURRED ❑ YES ❑ NO 221. LOCATION OF INJURY - STREET BNUMBER,APT.NO. CfIYITOWN STATE ZIPCODE 231,. IIATF nc..DEATH (Mo., Day, Yr.) r 241,. DATE SIGNED (Mo., Day, Yr.) 246.TIME OF DEATH ;s April 18, 2005 ��¢r rn ......... .....__ ......... ___E -1 y 23b.DATESONEb(Mo. ay,Yr.) 23o.TIMEOFDEATH_� y. 24c.PRONOu NCEDDEAD(Mo.,Day,Yc) 24d.TIMEPRONpUNCEDDEAD aa� E -- 4:19 Pm aaa� Ill E » a u° c O 23d. To a best of m knowls ,death occurred at the time, date and place 2° Title) T 1,w 24e. On the basis of examination and /or investigation, In my opinion death occurred at the,time, dale and place and due to the cause(s) stated. (Signature and Title ) T and due to the causes st ed. (Signature and cm r1, 00 rrtU `o DIDTOBACCOUSECONTRI TETOTHED AT 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? l 11 YES . -' NO 11 PROBABLY ❑ UNKN N U YES NO Not Applicable If 26a is NO C3 YES ❑ NO 27. NAME, TI BAN ADDRESS OF CERT IER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY AT ORNEY) (Type or Print) Island, Nebraska 68803 o don Hrnicek M.D. 729 G . Custer and 281,. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo.,oO�r.)