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<br />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 RECPfl'l!}~FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAnST/~SECT1!Jl"-'-l"#!!PH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~, ,,':#:;,,=-;'-.:':,_'1':~ Ji~, '-::-,;,_,,'_,-,:,_,~,;,,_
<br />
<br />DATE OF ISSUANCE __ =: ~1!X., ~-:.~ _ '-=1
<br />~ ?, TANLEt~CO~Ei
<br />DEe 2 0 2D(]5 AS~/SrAivt$fA.tJ1REG!S'riffl~
<br />LINCOLN, NEBRASKA HEA~rFtAND,,!UMAN SEF!::v..~~
<br />2 0 0 6 0 0 1 7 4 -!:\,t~t~,~:? "'- __
<br />~~.7. :.:~' "~:~:~~ 'i\.'< ~~. ::-~~ -~:-.
<br />STATE OF NE, BRASKA- DEPA, , R, TMENT OF H" EALTH AND HUMA" N" SERVICES Fi~-,~R:~\i~, - mAS ~ 1, ,40 4 7
<br />__ _ CERTIFICATE OF DJ;ATH "',,'-" .. ___.....:.~u,. '
<br />2. SEX 3. DATE OF DEATH (Mo" Day, Yr,)
<br />Female. December.._12 , 2005
<br />5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo" Day, Yr.)
<br />HOURS MINS,
<br />
<br />
<br />1. DECEDENT'S-NAME (First,
<br />
<br />Middle,
<br />
<br />LaSI,
<br />
<br />SuIfIX)
<br />
<br />Barbar~___----.il.___ Botsford
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE.Last Blrlhday 5b. UNDER 1 YEAR
<br />
<br />(yrs6)9 MOS'r DA_YS
<br />
<br />~~~~~ New Jersey ~
<br />''''''''''"''''"~"'" - I""~'~'W>
<br />
<br />JiQSEJIAI.' il Inpallanl
<br />
<br />Bb, FACILlTY.NAME (It nol inslitulion, give Slreel and number) 0 ER/Outpatianl
<br />
<br />
<br />Fai th R~gional He~l th Serv;i.ces
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />November
<br />
<br />5, 1936
<br />
<br />~
<br />
<br />o Nursing Home/LTC 0 Hospice Faclllly
<br />
<br />o Decedent's Home
<br />
<br />9b. COUNTY
<br />
<br />o [J)\ U Other (Specily)
<br />
<br />, ~rd. COUNTY OF DEATH
<br />
<br />__ Madison
<br />9c. CITY OR TOWN
<br />
<br />Madison
<br />
<br />Meadow Grove
<br />,-"F~o 91. ZIP CODE"'--~" S, IDE CITY LIMITS
<br />
<br />_ _~. 68752-___----.L..__1Kl YES 0 NO
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Suflix) If wife, give maiden name.
<br />
<br />215 Plea~ant St.
<br />lOa, MARITAL STATUS AT TIME OF DEATH !Xl Married 0 Naver Married
<br />
<br />U Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Howard BotSford
<br />
<br />11, FATHER'S.NAME (Firsl. Middle, Last, S,~lfIX) l12. M~,THER'S-NAME (First,
<br />
<br />~__JS~_ Locke ...._ Yiolet
<br />13, EVER IN U.S. ARMED FORCES? Glva dales of service II yas. 14a,INFORMANT.NAME
<br />
<br />..JYa~,~o,orunk,) Yes 1956,-1958, Howard Botsford
<br />
<br />15. ~:~r~a~ OF DI~::~::i:~ 15a EMBA~ER-SIGNAT~ ?3~<<4J ].1-6~;;pNO.
<br />
<br />W Cremalion 0 Enlomliment METER~TORY OR OTHER LOCATION CITY / TOWN
<br />
<br />Middle, Maidan Surname)
<br />
<br />AVaz::s.
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />lIJ,li5lband
<br />16c. DATE (Mo.. Dsy, Yr. )
<br />
<br />Dec~!l!Q.er 15 , 2005
<br />STATE
<br />
<br />I..J Ramoval 0 Olhar (Spaclly)
<br />
<br />Nebraska Cremation Service
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slraal, Clly or Town, Statal
<br />Brockhaus-Harlan Funeral Home 303 East 2nd Street, Tilden, Nebraska
<br />
<br />Norfolk
<br />
<br />Nebraska
<br />17b. Zip Code
<br />
<br />
<br />68781-
<br />
<br />
<br />
<br />PART I. Enter the ch.<!.!n....o~--dlseases. injuries, or compllcatlons--Ihat direClly caused the dBalh. DO NOT enter terminal events suoh as cardiac arrest,
<br />raaplratory arreat. or vantrlcular fibrillation wllhoulahowlng the etiology. DO NOT ABBREVIATE, Enlar only one cause on a Ilna. Add addllionalllna. It nacessary.
<br />IMMEDIATE CAUSE:
<br />
<br />onset to death
<br />
<br />(a) , '" L ih"~ ?A~.cA...-
<br />DUE TO, OR AS A CONSEOUEN E OF;
<br />
<br />""~k....
<br />
<br />h,
<br />
<br />)l:}R,J",,,.frt.:-h.....
<br />
<br />--4..."""""
<br />
<br />t;;.}N."r
<br />on sat to death
<br />
<br />IMMEDIATE CAUSE (Fin.'
<br />disease or condition resulting
<br />Indeatli)
<br />
<br />Sequentielly 11.1 condlllons, if (b)
<br />.ny,le.dlngtolh.c.usell.t.d DUE TO, OR AS A CONSEQUENCE OF:
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(dl..... or Inlury thatlnltl,'.d (c)
<br />Iheevenl...sultlng Indealh) DUE TO, OR AS A CONSEQUENCE OF:
<br />LASr
<br />
<br />onsel to death
<br />
<br />onsello dealh
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but nol ra.ultlng In Ihe underlying cau.e given In PART L
<br />
<br />19. WAS MEOICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES
<br />
<br />Il!l NO
<br />
<br />21 a. MANNER OF DEATH
<br />/iifljalural 0 Homicide
<br />
<br />o AccidenlO Pending Invesligelion
<br />
<br />U Suicide 0 Could nol be delermined
<br />
<br />21 b.IFTRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />lJ Passenger
<br />
<br />o Pedestrian
<br />
<br />o Other (Specify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES !Xl No
<br />
<br />o Not pregnant, but pregna.nl within 42 days of dea.th
<br />o Nol pragnant, but pregnant 43 days 10 1 year before dealh
<br />o Unknown II pregnanl within Ihe past year
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAilABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />o YES Xl NO
<br />22b. TIME OF INJUR,y-T22c_, PLAC,E Qr IN"~ip.LA1 hwa.. '.un. .u.at,JacMjl ofliu-WiJdin~, ~~-~Ik.n site, elt:;'(5p;~irY)-' --
<br />- ~-] .
<br />
<br />22d, INJURY AT WORK?
<br />
<br />
<br />22a, DATE OF INJURY (Mo" Dsy, Yr.)
<br />
<br />DYES 0 NO
<br />
<br />221. lOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYfTOWN
<br />
<br />STIllE
<br />
<br />ZIP CODE
<br />
<br />z
<br />~S
<br />ll!.!
<br />]l~
<br />c..:E:~
<br />E"-z
<br />8 g>o
<br />.8"g
<br />~:@
<br /><(
<br />
<br />23s, DATE OF DEATH (Mo.. Day, Yr.)
<br />}?ecember~__12, 200.~
<br />
<br />m
<br />
<br />24a. DATE SIGNED (Mo., Dsy, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />z>
<br />~~!l;!
<br />ll~~
<br />U<(~
<br />gn2J
<br />UUjz
<br />.8z:>
<br />00
<br />~a:u
<br />o~
<br />uo
<br />
<br />23b. DATE SIGNED (Mo., Day, Yr,)
<br />December 15,
<br />
<br />23C. TIME OF DEATH
<br />20 5 8:10 am
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the besl O~:6~wiedge, death occurred,81the lima, date end place
<br />and due to Ih,:{ ~e(s) alaled, (Slgnalura and Tille)"
<br />
<br />(.A>1,l<< (J, ?<,.fL.ftJ
<br />
<br />248. On the basis of examination and/or irwesllgatlon, in my opinion death occurred at
<br />Ihellme, dale and place end due to the cause(s) Slated, (Signatur. and Tille)"
<br />
<br />25. DID TOBACCO USE CONTRIBUTE OTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />,.._J!!!:. YES _lJ N_O [J PROBABLY. ..,0 UNKNOWN ,,__ 0 YES "._ ~NO __.. ~~Ol Appliceble if 26a is ~O 0 YES i1lii NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Dr. Gary Smith, M.D., 2600 Norfolk Ave. Ste. B, Norfolk, NE 68701
<br />
<br />A\
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<br />
<br />
<br />IDE'" '6 IJ ,.. , )1'
<br />LiJ "" J. 07 lm;~
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
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