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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORDS €ILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS-SECTJ�7A .:Vi ECI IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />SEP 0 6 2005 TANLE OOPERr
<br />LINCOLN, NEBRASKA 200509051 ASSISTANT STATE Rims T -RAR
<br />HEALTH AND HUMAN SERVICES=
<br />STATE OF _�- _
<br />NEBRASKA - DEPARTMENT 1?I= HEALTH AND HUMAN SERVICES FINANCE A146 $ 1PPS7R-T
<br />CERTIFICATE OF DEATH
<br />I. DECEDENT'S -NAME (First, Middle, Last,
<br />2. SEX 3, DATE OF DEATH (Mc., Day, Yr.)
<br />Jonathan Paul Borer Male August 22, 2005
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH sa. AGE -Last Birthday 5b, UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) MOS. DAYS HOURS MINs.
<br />Atkinson, Nebraska 38 March 1, 1967
<br />7. SOCIAL SECURITY NUMBER - -
<br />ea.PLACE DFDEATH
<br />506 -98 -0225
<br />HOSPITAS: ❑ inpatient OTHE5; ❑ Nursing Home /LTC LI Hospice Facility
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />❑ ERlOulpetient I Decedent's Home
<br />4 0 21 Reed Road _ a pa+ ❑ Other (Specify)-- -
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a.RESIDENCE-STATE COUNT -
<br />gb. Y 9c ... .... ., -
<br />. CITYOR70 WN -
<br />Nebraska Hall Grand Island
<br />9d. STREET AND NUMBER -
<br />Be APT NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />4021 Reed Road 68803 YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH -- - -- --
<br />Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, give maiden name.
<br />L_I Married, but separated Cl Widowed U Divorced U Unknown
<br />.. Sandra LeMunyan
<br />11, FATHER'S -NAMF, (First, Middle,
<br />e � Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />._ . T n G p e �... _ _R° t -a e-><chm_u t
<br />13. Ye EVER IN U.S. ARMED FORCES? Give dates of service if Yes, 14a.INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />(ves, no, orunk,) No Sandra Borer
<br />-- _ Wife
<br />15. METHOD OF DISPOSITION 16
<br />��yy a. EMBALMER- SIGNATURE 166. LICENSE N0, -16c DATE (Mo., Day, Yr. )
<br />Lhurial ❑ Donation '! �'T :
<br />�........4.L 1.38- - Alm - 2
<br />16d. CEMET•Y, CREMATOR OTHER LOCATION STATE
<br />El Cremation ❑ Entombment CITY /TOWN TOWN
<br />❑ Removal LJ Other (Specify)
<br />Grand Island City Cemtery Grand Island Nebraska
<br />17a . FUN ERA L HOME NAME AND MAILING
<br />ADDRESS (Street, City or Town, State)
<br />_ - Tlie, zip coda
<br />18. PART I. Enter the nalm e1 events -- diseases, Injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology, DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Imes II necessary, l
<br />IMMEDIATE CAUSE: onset to death
<br />I
<br />IMMEDIATE CAUSE (Final (a) Massive head in'uries 'immediate
<br />diseeseorconditionresu8ln - - "mot - 1...,
<br />In death) 9 DUE TO, OR AS A CONSEQUENCE OF; - --
<br />onset to death
<br />l
<br />Sequentially list conditions, if (b) self- inflicted gunshot
<br />any, leading to the cause listed - - -
<br />a DUE T0
<br />online a. , OR qS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that initialed (c)
<br />the events resulting In death) - - -' - --
<br />LAST DUE TO, DR AS A CONSEQUENCE OF: I onset to death
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES ❑ NO
<br />20, IF FEMALE: 21a. MANNER OF DEATH 21b, IF TRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />r
<br />❑ Not pregnant within past year ❑ Natural ❑ Homicide L) Driver /Operator
<br />❑ Pregnant at time of death L,I A ❑ Passenger El YES V NO
<br />ccideniL] Pending Investigation
<br />❑ Not pregnant, but pregnant within 42 days of death �.y� ❑ Pedestrian - --
<br />'1:.15uicide U Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />t ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Other (specify)
<br />COMPLETE CAUSE OF DEATH?
<br />l) Unknown If pregnant within the past year 11 YES YJ NO
<br />22a. DATE OF INJURY (Mo , Day, Yr.) 722b.T11IMEOFINjURY 22c. PLACE OFINJURY -At home, farm, street, lactvey, office building, construction site, etc. (specify)
<br />Au uc�st 22, 2005 7:45 am home
<br />22d. INJURY AT WORK? 226. DESCRIBE HOW INJURY OCCURRED - -- --
<br />❑YEB Q "° self - inflicted gunshot wound
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CRYlTOWN STATE ZIPCODF,
<br />4021 Reed Road Grand Island NE 68803
<br />Y 23a. DATE OF DEATH (Mo , Day Yr)_ -
<br />r
<br />y z� 24a.DAT SIGNS (Mo, Day, Yr.) 24b.TIMEOFDEATH
<br />q J _ 7:45 am
<br />U -to
<br />r w 23b. DATE SIGNED (Mo., Day, Yr,) 23c.TIME OF bE
<br />ATH' _ 24c. PRONOUNCED DEAD (Mo,, Day, 24d. TIME PRONOUNCED DEAD
<br />9QJ . m a�az August 22 2005 8:15am
<br />p
<br />} t., E 0 23d. To the best of my knowledge, death occurred at the time, data and lace S i 0
<br />p z 24e. On th asis�fe minali n a /or invesllgallon, in my opinion death occurred at
<br />¢ and due to the cause(s) staled. (Signature and Title) ♦ ¢ e th II , date a lace nd u o the causa(e) staled. (Signature and Title)
<br />C ~ c0i
<br />�...
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? w 26b, WAS CONSENT GRANTED?
<br />dv� +` ❑ YES X) NO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO YY
<br />- - -- Not Applicable if 26a Is N° -fir❑ YES_ C] NO
<br />�). 2.7 NA ME,TITLEANDADDRESSOFCERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (TypeorPrint) �1 Sou Locu .7 -Gt
<br />Michelle J. Oldham, Chief Deputy Hall County, Attorney, Grand Island, Nebraska 6880
<br />28a, REGISTRAR'S SIGNATURE
<br />286, DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />VX 1 SEP -1 2005
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