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<br />STATE OF NEBRASKA 8k 2005 Q 2S3lp
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICEI ()
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD OMIJ...E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTlCS.$Ec,!IfM",irr~/S
<br />
<br />:::;::~::::::~TORY FOR VITAL RECORDS. # ~..~:i=~'~~iI:.,.,...:.~(f;ij.--~~:.~.~\.m
<br />
<br />""'''-r7JT4NCa' $, GOO~$".-
<br />AUG 0 9 2005 200611052 AssiSTANT $~TEREGlIlTFjAR O'
<br />LINCOLN, NEBRASKA HEALtH ANQ HUMAN ~RV~S'.,
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<br />....-4""~
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<br />STATE OF NEBRASKA - DEPART. .M..E. .NT OF HEALTH AND HUMAN SERVI..C. .ES F. INANCE ANO~!J!'cpo..~.R.._T.-:".. 0'5" .'. 0 868 3
<br />c;ERTIFICATE OF DEATH_.. mn__ ...., .~__ _
<br />DECEDENT'S.NAME (FI"t, Middle, Lasl, Sulllx) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Jeanetta Boeka Female July 31 , 2005
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRHi
<br />
<br />Sa. AGE.Last Birthday
<br />(Yrs.)
<br />
<br />91
<br />
<br />5b. UNDER 1 YEAR
<br />MO:JDAVS--
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />R~ Cloud, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />8a. PLACE OF DEATH
<br />!:JmJl'lIAl. .
<br />
<br />~.Inpallenl
<br />
<br />OlliEB: 0 Nursing Home/LTC U Hospice Facl11ty
<br />
<br />July .~_5, 191~___
<br />
<br />. ~--~ 'O"'I'lOcillm'sHoiYW'.--.-"'---.
<br />
<br />8b. FACILlTY.NAME (If not Inslltutlnn, give streel end number)
<br />
<br />. - 0 EFf/Oofpa1illnl
<br />
<br />80. CITY OR TOWN OF DEATH (Inolude Zip Cod.)
<br />
<br />o D:Y\ 0 Olhar (Spa oily)
<br />
<br />...'. ___=r8d.C~~;::~E~TH
<br />
<br />9<:. CITY OR TOWN
<br />
<br />...I~~~~o
<br />
<br />
<br />9UIP CODE
<br />68845
<br />
<br />9d. STREET AND NUMBER
<br />5410 17th Avenue
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH 0 Married 0 N.var Marrl.d tOb. NAME OF SPOUSE (First, Middla, Lasl, Sulllx) If wlf., glv. maiden name.
<br />
<br />o Merrled, but separatad iJ(Wldowed 0 Dlvoroed 0 Unknown Loyd Boeka (died in 1983)
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<br />11. FATHER'S.NAME (Ft"l,
<br />Charles
<br />
<br />Middle,
<br />Luther
<br />
<br />Lasl, sulllx)
<br />Crabill
<br />
<br />12. MOTHER'S.NAME (First,
<br />Gertrude
<br />
<br />Middle,
<br />
<br />M.
<br />
<br />(Yes! no, or unk.)
<br />
<br />No
<br />
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glv. dates 01 service II yes.
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />IJilBurlal
<br />
<br />o Donallon
<br />
<br />o Crem"lIon U Entombment
<br />
<br />U Removal 0 Olhar (Sp.olfy)
<br />._._....._.._ _ W()(')Q Ri vpr r.pmetery Wood Ri yer,
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Str..I, City orTown, Slale)
<br />Apfel Flmeral Home 411 West 11 th Street Wood River Neb.raska
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<br />
<br />PART I. Enler the .c..balt:t,of"everJ.!$.--diseases. injuries, or complicalions--thal directly oaused the death. DO NOT enter tarmlnal events such as cardiac arrest,
<br />resplralory arresl, or ventricular fIbrillation without showIng the etIology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additlonalllne.s if necessary.
<br />
<br />IMMEDIATE CAUSE (Flnol
<br />dlseage or condition resulting
<br />In d.olh)
<br />
<br />IMMEDIATE CAUSE:
<br />(a) COil fYJ 1.!Y1f tlU.\y", fulll-lY~
<br />DUE TO, OR AS A CONSEQUENCe OF.
<br />
<br />S.quentl.lly 1101 conditions, II
<br />ony, I..dlng 10 Ihe cau.e 1I.led
<br />on lInei!l.
<br />En'.r 'h. UNDERLYING CAUSE
<br />(dl..... or Inju,\, th.t Initiated
<br />tho .v.nl. r..ultlng In deelh)
<br />tASf
<br />
<br />. .(~)__!~l\j-q,-( h~lM"~[k'~~::~.~,_
<br />
<br />DUE TO, OR AS A CONSEQU CE :
<br />
<br />~~.<::'..~1:'~~~~~J ftytt:~"J l)(kv.,,-L
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />A Cl,.-4{ iletter;{-
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITlONS.Condltlon. contributing 10 the de.th but nol re.ulting In Ih. und.rlylng cau,e glv.n In PART I.
<br />
<br />f\ u,d.t,
<br />
<br />t/..o1/1<.f F-itj lwc Ckt1Nlfl: <<-OWe F~li!""l'(_
<br />/
<br />
<br />20. IF FEMALE:
<br />llf'NOI pregnant within past year
<br />o pr.gnanl .tllme of death
<br />o Not pr.gnant, but pregnant wllhln 42 d.y. of d.ath
<br />o NOI pr.gnant, bul pragnonl 43 d.ys 10 1 y..r b.fore dealh
<br />o Unknown II pregnanl wllhln Ih. past v..r
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<br />21a. MANNER OF DEATIi
<br />l.J1f;lur.1 0 Homlolde
<br />
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />9g. INSIDE CITY LIMITS
<br />~ YES 0 NO
<br />
<br />., M.lden Surname)
<br />Ford
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Dau hter
<br />160. DATE (Mo" Day, Yr. )
<br />. .~1,!g1,1SLlt 2005
<br />STATE
<br />
<br />Nebraska
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />I
<br />I
<br />
<br />I ons.,to d.ath
<br />I
<br />I
<br />I
<br />I onsel to death
<br />I
<br />I
<br />I
<br />I onsello dealh
<br />I
<br />I
<br />,
<br />
<br />onset 10 death
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<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES
<br />
<br />13"" N 0
<br />
<br />o Passenger
<br />o Pedestrian
<br />
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />U Drlver/Oparalor
<br />
<br />Q YES
<br />
<br />r:rr:rO
<br />
<br />o AocidentD Pending Inv.sllg.tlon
<br />Q Suicide 0 Could nol be determined
<br />
<br />o Oth.r (Speclly)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILA8LE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />
<br />22.. DATE OF INJURY iMo, Day, Yr.) 22b. TIME OF It'JUR~~-PL:\i'E OF INJURY AI lIome, ""'r, 5t:I':"f~;Y-::tl~~:'~~ing. con,truollen '''., .fe. (Sp.olly)
<br />
<br />
<br />22d.INJURY AT WORK? 22.. DESCRIBE HOW INJURY OCCURRED
<br />
<br />U YES 0 NO
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<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />~1 .- 3 I .~~ 05"__.
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />iJ .. 3" C5
<br />
<br />24.. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />z>-
<br />~~~
<br />~~~
<br />D.D.4:(~
<br />E ."~ ~
<br />8 ffi z '
<br />Jl~S
<br />~a:o
<br />8!l
<br />
<br />25. DIDT08ACCO Ui~ CONT IBUTETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />DYES ri 0 PR08A8LY 0 UNKNOWN 0 YES 13-M1T"""
<br />27. NAME, nrLEAND ADDRESS OF CERTIFIER (PHYSICIAN'-66iioNER'S PHYSICIAN OR COUNTY ATTORNEY)(Typ~'orPrlnl)
<br />G ~
<br />
<br />230.TIME OF DEATH
<br />~:05"m
<br />
<br />24C. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />m
<br />
<br />ZIP CODE
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<br />24b. TIME OF DEATH
<br />
<br />24e. On the basIs of examInation and/or Invesligatlon, in my opinion death occurred at
<br />Ih.lim., date and place and due to Ihe causer') "aled. (Signa Iura and Titl. I '"
<br />
<br />28b. WAS CONSENT GRANTED?
<br />
<br />rJt:
<br />
<br />Nol Applicable II 26e I' NO 0 YES 13l-Ncr--
<br />
<br />t. J"'I>t/S~
<br />
<br />AUG
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Vr.)
<br />
<br />8 Z005
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