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' WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH.AND HUMAN SERVICES SYSTER IT CERnF/ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORD& DATE OF ISSUANCE' 7/23/2003 200810468 ANLEYa COOPER ASSISTANT STATE REGISTRAR UNCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASK/�- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE: OF T)RATU 1. DECEDENT - NAME FIRST MIDDLE LAST Edith Elizabeth Bosselman Z. SEX Female 3. PATE OF DEATH AtwO& June 27, 2003 M, CITY AND STATE OF BIRTH Tyro/n U." name WW*y) SL APE - law BWalay I UNDER 1 YEAR UNDER 1 DAY ! DATE OF BIRTH (Mart Day. Yea? Grand Island, Nebraska rfml 80 1 November 23, 1922 & MM DAYS ft- NOM MINE. [$ A [] U ldewrm n.d 1? . w'e e o May 20'1 unk M . ❑ Sur de ❑ Pargirg 2Be, INJURY AT WO�RK Y` 2&, PLACE OF INJURY % to hory". term abeeL leclory 24 LOL'ATgN STiiEEf OR RF.: NO. CfTY OR TOWN STATE I 27a DATE OF DEATH IMa.. Day Yr) _ 29a DATE SONEO /Ada. Day. yr.) 2Bb, TIME OF DEATH s !a3 I;- M 7. SOCIAL SECURTIY NUMBER U PLACE OF DEATH 505 - 58-0685 FrosPrvLL ® kpww OTHER: ❑ Nuraalp Were awed Is 1M WIN. rode and place tYltl dUa tD U1e Gueela) mNd ❑�ER OuOON M Retuderlce Ili. FACLUTY - Name if we w -swa k%9754 Mw aw maw Bryan -LGH West C OCA 301 WAS CONSENT GRANTED? YES NO UNKNOWN Ilc. CITY. TOWN OR LOCATION OF DEATH Bd INSIDE CITY LIMITS w. COUNTY OF DEATH Lincoln, Nebraska Yea [A I Lancaster 9a RESIDENCE • STATE pb. COUNTY 9c. CITY. TOWN OR LOCATION 21 STREET AND NUMBER /MdudhyZ7p Cade) 9e, INSIDE CITY LIMITS Nebraska Hall Grand island 1321 North Vine St. 68801 Y. 10. RACE - lap.. WMw. Bleclr. Mrwnoan Indian. White 11. ANCESTRY leq_ ILellen. Meeker' Gorman, awl 12 ❑ MARRIEb ❑ WIDOWED I& NAME OF SPOUSE /K wik g w maiden rwrrw) .tw rsb.alrl (sPwoNNI American NEVER DIVORCED Clarence Bosselman 14a USUAL OCCUPATION JG" kW of l ,y�. dau dump d.n*.vAy ~y1 homemaker 7�n• KIND OF BUBIN INWSTRY 1/oTestic 15. EDUCATION (SpaCily Fade EWMw WYgSf0lXk"fD.12) GOYapa 114 wS-1 IS. FATHER - NAME FIRST MIDDLE LAST 17, MOTMER FIRST MIDDLE MAIDEN SURNAME Chris Pollock. Elizabeth Roth 13, WAS DECEASED EVER IN U.S- ARMED FORCES? IS& INFORMANT -NAME ryft Munk,) I"'"` p" aaa and da"e °''"vi`a'l Clarence Bossellman 19b, INFORMANT MAILING ADDRESS (STREET OR RFD. NO, CRY OR TOWN. STATE 1321 North Vine St., Grand Island, Nebraska 68801 MBALMER - TURF 8 E NO. 21 a METHOD OF DISPOSTION 214 DATE 21c. CEMETERY OR CREMATORY NAME �� #1071 R C-- ❑ D.— July 1, 2pp3 Grand Island Cemetery ZU FUNERAL HOME -NAME All Faiths Funeral Home 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR RFD. NO_ CRY OR TOWN. STATE, Z 2929 S. Locust St., Grand Island, Nebraska 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR fU ft AND loll 1 k"Nal Dot~ onset and death PART !n r � ^ i lal 1 I ! DUE TO. OR AS A CONSEOUFACE OF: I Mwra b.ay.!r. (blr�.. n 92g-ey p i�jt,vyLd� (. (,, 7. ..., ial e _ _ � elwrYal [IefM'eerl d1eM M10 De�p r _t Inn Fl) M r 91 N. OTHER SIGNIFICANT CONDITIONS - CMCJ4i =VhU0W p the death b1A not rwaled T PART PART 01 IF FEMALE- WAS THERE A 24 AUTOPSY 14. WAS CASE REFERRED TO MEDICAL , PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? (Awe 10-541 Yw R No Ya No Y. No 26a 25b. DATE OF INJURY IAA . Day: Yij s&. HOUR OF INJURY 25d DESCRIBE HOW II:JRY OCCURRED A r ox 11 [$ A [] U ldewrm n.d 1? . w'e e o May 20'1 unk M . ❑ Sur de ❑ Pargirg 2Be, INJURY AT WO�RK Y` 2&, PLACE OF INJURY % to hory". term abeeL leclory 24 LOL'ATgN STiiEEf OR RF.: NO. CfTY OR TOWN STATE -1 ❑ H InawgAw Yep ❑ l`/1 home 1321 N. Vine Street Grand T d Y� 27a DATE OF DEATH IMa.. Day Yr) _ 29a DATE SONEO /Ada. Day. yr.) 2Bb, TIME OF DEATH s !a3 I;- M 2%, DATE SIGNED IMa. Day. Yr.) 27c• TIME OF DEATH 2k PRONOUNCED DEAD IMP. Day, Yr.) 264 PRONOUNCED DEAD INq y 7 1 Q3 ca M M 'to 27d. Ito b6 A In occwrod At Yw *ne. date, and Noce wW d. b 14e 2 2Ea On t o basis III Maui ",Or � arweapwill h my apMJon dawn occurred >V awed Is 1M WIN. rode and place tYltl dUa tD U1e Gueela) mNd ( IM aM Tore TMM b. 29 d0 TOBACCO USE TRIBUTE THE DEATH? 3Da HAS ORGAN OR TISSUE DDNATIDH BEEN CONSIDERED? 301 WAS CONSENT GRANTED? YES NO UNKNOWN K YES NO '�j� YES ND 31. NAME AND ADDRESS OF COTInER IPHYSICUW. CORONER'S PHYSICIAN OR COUNT( ATTORNEY( /Tjprggk4 David Cockerill, M.D., 1500 South 48th St., Suite 511; Lincoln, Nebraska 68506 32A REGISTRAR 32b. DATE FILED BY REGISTRAR IMa. Da , Yr.I JUL 1 2003