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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HCJMANSERVlCES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIN/ft/Rf!.t;01JD.'!WF1I..fi WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sTArsr/e~SEf;:tJ(jN;:WH'CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS .,.T. '''.''''.-,,~:0':'j.' . ='_.-.c.o:""', "
<br />
<br />
<br />MAyATOiZOOSNCE . ~~~;R
<br />2 0 0 6 0 .. 2 5 1 Assl!itANTsrA~RE~/ifr~AR
<br />LINCOLN, NEBRASKA HEAl..TH 4NDJm"~NSERVlCES
<br />
<br />
<br />S. TATE OF NEBRAS.. KA'- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORO 6
<br />CERTIFICATE OF DEATH
<br />. ... .,',.'_' . ~,..__ ..u ,_n ______ ' ..- ,,,.
<br />
<br />246,90
<br />
<br />1.DE'CEDE'NT'S-NAME' (First,
<br />
<br />Middle,
<br />
<br />Lasl,
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />
<br />Fgm9. e
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF DEATH (Mo.. Day, Yr.)
<br />April 19. 2006__
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />Nancy Elaine
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Bolt~
<br />5a. AGE-Lasl Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />70
<br />
<br />July 11. 1935
<br />
<br />Friend. Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />8a. PLACE OF DEATH
<br />1iQ.SEJIAl.:
<br />
<br />o Inpallenl
<br />
<br />QIl:lE8; Xl Nursing Home/LTC U Hospico Focilily
<br />
<br />505-48-6041
<br />
<br />I G:::":::~:::::' ::::"~r"'" "co" ,", "",',,'
<br />
<br />
<br />'~lid'li Be. CITY OR TOWN OF DE'ATH (Include Zip Codo)
<br />
<br />liffi~..VJood River 68883
<br />:I;~ 9a. RESIDENCE-STATE
<br />
<br />~;J:: Nebraska
<br />i~: 'i,r 9d. STREE'T AND NUMBER
<br />
<br />,:~. ~1__187,1 West 7 Street
<br />'1 iP 10a. MARITAL STATUS ATTIME OF DEAfH ~ Married 0 Never Married
<br />II:
<br />o Married, but 'eparated 0 Widow ad 0 Divorced 0 Unknown
<br />
<br />U ER/Outpatierll
<br />
<br />o Decedenl's HolYlp.
<br />
<br />OCO\
<br />
<br />o Other (Specify)_~ ...~
<br />
<br />Bd. COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />'-1'9~:T::R~0~ s l-a~-d
<br />- ~.. 9fZ~;;~!
<br />
<br />10b. NAME OF SPOUSE (Flrsl, Middle, la.t, Sutfix) If wile, give maiden name.
<br />
<br />___-'~~~7
<br />
<br />9g. INSIDE CITY LIMITS
<br />~\,ES 0 NO
<br />
<br />
<br />Roy Boltz
<br />sulfix) fOTHER'S-NAME
<br />
<br />(First,
<br />Lillian
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Belka
<br />
<br />11. FATHER'S-NAME (Flfst,
<br />Cecil
<br />
<br />Middle,
<br />
<br />LaS!,
<br />West
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of service If yos. 14'.INFORMANT.NAME
<br />No Roy Boltz
<br />
<br />14b. RELATIONSHIP TO DE'CEDENT
<br />Husband
<br />
<br />15. METHOD OF DISPOSITiON
<br />~urlal 0 Donation
<br />o Cromallon .0 Enlombment
<br />
<br />1B'.EMBALMER-SIGNATURE _...~
<br />
<br />
<br />16d~CEMETERY, CRE:~~R l~
<br />
<br />16b. LIC~NSE NO.
<br />'1 $Z..s'
<br />
<br />16c. DATE' (Mo" Day, Yr.)
<br />April 24. 2006
<br />STATE
<br />
<br />CITY /TOWN
<br />
<br />o Ramoval 0 Olher (Specify)
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />Grand Island. Nebraska
<br />
<br />17b. Zip Code
<br />
<br />PART I. Enter the !WJ!.\n...9i~yen1S.--dlsaases, injuries, or compllcatlonSn\hat directly caused the death. DO NOT enter termInal events such as cardIac arrest!
<br />re'plratory arrest, or vantrlcular IIbflliation wilhout showing the etiology. DO NOT ABBREVIATE. Entar only one cau,e on a IIno. Add addlllonalllnes It necossary.
<br />
<br />IMMEOIATE CAUSE:
<br />
<br />onset to death
<br />
<br />(a)
<br />
<br />'fV'-e \~ s.~ '-
<br />
<br />Q, .[' { (\- <;-\-
<br />
<br />CI\A It.-I''\..
<br />
<br />I r- \'; '\ I'U
<br />
<br />I onsat to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dlsea$e Of condition resulUng
<br />In death).
<br />
<br />Sequentlelly II.' eondlllon., If (b)
<br />any, leading to the cau,e listed - DU~'TO, OR AS A CONSEQUENCE-OF:
<br />on line H.
<br />Enter tho UNDERlYING CAUSE'
<br />(dl.o.ae or Injury Ihal initiated (c)
<br />Iheeventsr..ulllng In de.th) DUE TO, OR AS A CONSEQUENCE OF:
<br />lASf
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />lB. PART II. OTHER SIGNIFICANT CONDITIONS.Condillons contributing 10 the doath but nol resulting in tho underlying oause given in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES .l("NO
<br />
<br />\~ t.l-l'l~
<br />
<br />20. IF FEMALE:
<br />~Not pregnant within past year
<br />o Pregnant al1ime 01 death
<br />
<br />21a. MANNER OF DEATH
<br />~Natural U Homicide
<br />
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />DYES
<br />
<br />>.(NO
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />o NOI pregnant, but pregnant within 42 days ot death 0 Suicide [J Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABl.UO
<br />o NOI pregnant, but pregnant 43 days 10 1 year bofore death 0 Olher (Spocity) COMPLETE CAUSE OF DElifH?
<br />
<br />o Unknown II pregnant within the paS! year 0 YES 0 NO
<br />
<br />'-2-2a.DA~~OF INJURY (Mo.,D~Y, vr.,-] 22b.TIMEO:~NJUR;]22~~PLACE_~~INJUR.Y'AI ho;;~, f.rni'-alr~:et, '.cto~~fiiC~~lIding: conslrU~II~'~il., elc. ~~.cIlY) -~,~ ----.
<br />
<br />
<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />o AccidentD Pending Investigation
<br />
<br />DYES 0 NO
<br />
<br />221. LOCAflON OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CtTYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />Hii
<br />~l3z
<br />j,iil'"
<br />ji~~
<br />D. C. iIC[ ::;
<br />E &~ 2:: z
<br />8ffizO
<br />..z::>
<br />.DoO
<br />t2a:O
<br />o~
<br />(Jo
<br />
<br />"-\- \q~ ol.o
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />.t2 lIS m
<br />
<br />24C. PRONOUNCED DE'AD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or invesllgatlon, in my opinion dealh oocurred at
<br />the time, date and place and duo to Ihe oause(s) statod. (Signalure and Tillo) l'
<br />
<br />25. DID TOBACCO USE CONTRIBUT 26b. WAS CONSENT GRANTED?
<br />
<br />_0 YES_._~9._~~<::>~~~_KNOWN 0 YES ,6; NO _ Not~ppiloeble It 26a Is NOnO YES ~00
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (pHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Steve Husen M.D. 2116 W. Faidley Grand Island. Nebraska 68803
<br />
<br />y
<br />
<br />
<br />APR 2 7 2006
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />28b. DATE FILED BY REGiSTRAR (Mo" Day, Yr.)
<br />
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