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<br />STATE OF NEBRASKA
<br />
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<br />
<br />
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<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAI.]'f-ri,"llt/~IYNi'Y. SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE- WITH THE N. E~I;(~. . vJ~M1.T1f1J;ljl.. J~F.. H. EAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORy.f..ifFt~~4--~~D,~~(>~~, U J-
<br />
<br />DATE OF ISSUANCE . ,~~IJ" ,.', ',.., . /_ '..,....~~._
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE A~dSf;!,\", FI'r .f)Q_";,:~
<br />CERTIFICATE OF DEATH / ..; '-,\::1'0"' ,.)
<br />
<br />DEe 11 2008
<br />
<br />200900382
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />1. DECEDENT'S-NAME (FlrSI,
<br />Flo d
<br />
<br />Mlddl.,
<br />Frank
<br />
<br />Leot,
<br />Bachkora
<br />
<br />Sulllx)
<br />
<br />2, SEX
<br />Male
<br />
<br />3'.IlATE OF DEATH (Mo.. Day, Yr,)
<br />November 19, 2008
<br />
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa, AGE-La.t Birlhday
<br />(Yrs_)
<br />
<br />
<br />5c, UNDER 1 DAY 6. DAn OF BIRTH (Mo.. Day, Yr_)
<br />MINS_
<br />
<br />Nebraska
<br />
<br />80
<br />
<br />March 7, 1928
<br />
<br />507-48-8717
<br />
<br />e.. PLACE OF DEATH
<br />/:lQ.aflIAl.;
<br />
<br />a Inpatlonl QIlJB: [J NurSing HotIIoILTC [J HOSPice FacUily _
<br />
<br />8b. FACILitv.NAliE(i1 ~~llnelltuti;n:- gl..--str.81--;;;a "Umb~;;--'---
<br />
<br />o ER/Oulp.llent 0 Decedent's Hom.
<br />
<br />Good samaritan Hospital
<br />
<br />8c. CITY OR TOWN OF DEATH (Includ. Zip Cad.)
<br />Kearney
<br />90_ RESIDENCE.STATE
<br />
<br />o [l)', 0 Olh.r (Specify)
<br />
<br />8d, COUNTY OF DEATH
<br />Buffalo
<br />
<br />Nebraska
<br />Sd. STREET AND NUMBER
<br />
<br />91>, COlJNTY
<br />Buffalo
<br />
<br />
<br />91. ZIP CODE
<br />68847
<br />
<br />9g. INSIDE CITY LIMITS
<br />XI YES 0 NO
<br />
<br />2701 Grand Avenue
<br />
<br />- .
<br />10a_ MARITAL STATUS ATTIME OF DEATH Xl Ma"l.d 0 N.v.r Ma"iad lOb. NAME OF SPOUSE (First, Middlo, Last, Sullix) If wit., gi.o mald.n nam.,
<br />
<br />o M."led, but s.por.l.d 0 Wldow.d tJ Divorc.d 0 Unknown
<br />
<br />Vera Williams
<br />
<br />11, FATHER'S.NAME (Flrsl,
<br />Charles
<br />
<br />Middl.,
<br />
<br />La.', Sufllx)
<br />Bachkora
<br />
<br />12. MOTHER'S.NAME (First,
<br />Lucy
<br />
<br />Mlddl.,
<br />
<br />Mald.n Surn.m.)
<br />McDonald
<br />
<br />13. EVER IN U,S, ARMED FORCES? GI.. d.t.. 01 s.r.lcell ye~, 14.,INFORMANT.NAME
<br />(Y.s,no,~'.~nk,) Yes 1/8/53-6/15/54 Vera Bachkora
<br />1 s, METHOD OF DISPOSITION 18a_ EMBALMER-SIGNATURE
<br />Cl Burl.1 ODonalion Not embalmed
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />18b, LICENSE NO_
<br />
<br />lX:r.m.llon 0 Entombm.nl
<br />o R.mo.al 0 Othor (Sp.clfy)
<br />
<br />16d_ CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY I TOWN
<br />
<br />16c_ DATE (Mo.. Day, Y,- )
<br />November 21 2008
<br />STATE
<br />
<br />Josten Cremation Service
<br />
<br />Kearney
<br />
<br />Nebraska
<br />
<br />17., FUNERAL HOME NAME AND MAILING ADDRESS (Streot, City or Town, SI.I.)
<br />O' Brien-straabnann FUneral Hone 411 5 Avenue N
<br />
<br />Kearney, NE
<br />
<br />17b. Zip COdo
<br />68847
<br />
<br />PART I. Enlor tho ~landis.Osos, inJurl.s, or complicalions..th.1 dlr.clly cau..d the d.elh. DO NOT ont.r termlnel.vonl. such as c.rdl.c a"..I,
<br />respiratory arrest. or ~enttlc:ular fibrllla.tion wlthoul $l'1owing the etiology, 00 NOT ABBREVIATE. Enter only one cause on a Ill'le. Add additionalllnl!ls If necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />on.ollo d.alh
<br />
<br />IMMEDIATE CAUSE (Final
<br />d_",conditlon rHulUng
<br />In_h)
<br />
<br />(.) c.~Jt.<4~ 1f~J.
<br />DUE TO, OR AS A CONIEQUENCE OF: ...,
<br />
<br />onset 10 de.lh
<br />
<br />Saqu.nttally lI.t conditione, If
<br />.ny, ItadlnS to lhe cau..ll11ad
<br />on line 8.
<br />EntertheUNDERLYING CAUSE
<br />(dl..... or Injurythlt Initialed
<br />lheownt....ultinSln_h)
<br />LASr
<br />
<br />(b)
<br />
<br />{....Q f i'J -
<br />
<br />~-
<br />
<br />_n _
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />ons8t to death
<br />
<br />(c)
<br />
<br />~T
<br />
<br />k;
<br />,
<br />
<br />~~~~.Accidental
<br />
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />
<br />ons.t 10 d.alh
<br />
<br />(d)
<br />
<br />PART II, OTHER SIGNIFICANT CONDITlONS.Condlllons conlrlbullng to tho d..th but not r.Bulllng in Iho undorlylng cau.e given In PART I.
<br />
<br />il!IAcclden,O P.ndlng In...llgallon
<br />
<br />21 b.IFTRANSPORTATlON INJURY
<br />o Dri..r/Op.r.lor
<br />
<br />o P....ng.r 41'1
<br />
<br />o P.d.slrl.n
<br />
<br />1:1 Olhor (Sp.clly)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />DR CORONER CONTACTED?
<br />o YES NO
<br />21c_ WAS AN AUTOPSY PERFORMED?
<br />
<br />20, IF FEMALE:
<br />a Not pregnant within past year Jf9
<br />o progn.nt .1 11m. 01 d.olh
<br />o Not pregnon" but pr.gn.nl within 42 d.y. 01 d..lh
<br />o Not pregnant, bl.it pregnant 43 days to 1 year before dBIUh
<br />o Unknown II pr.gnant within Ih. paBt y..r
<br />
<br />210, MANNER OF DEATH
<br />JlIJ...u,al 0 Homicide
<br />
<br />o YES ~NO
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAuSE OF DEATH?
<br />IJ YES 0 NO
<br />
<br />22b. TIME OF INJURY 22C, PLACE OF INJURY-At homo, farm, strae" '.ctory, offlco building, construclion .if., otc_ (Sp.clty)
<br />Horne
<br />
<br />221, LOCATION OF INJURY. STREET & NUMBER, APT. NO, CfT'f/TOWN
<br />
<br />2701 G _~n_d AveL.JJ71.-4-
<br />23a_ DATE OF DEATH (Mo., Doy, Yr_1 ")
<br />" -JJ -Vo
<br />23b, DATE SIGNED (Mo.. D.y, Yr,) 23c_ TIME OF DEATH
<br />J~-..11-9~ ~I: 1 m
<br />
<br />81m ZIP CODE
<br />
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr,) 24b, TIME OF DEATH
<br />
<br />
<br />~'?c~_
<br />
<br />liU
<br />h~~
<br />fiH~
<br />llziil
<br />,2~~
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr,) 24d_ TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the best of my knowledge, death occurred at the time, dale and place
<br />and due to the cause(s) stated. (Signature and Title) .
<br />
<br />24e. On the basis of exsmlnation and/or investlgatlon, In my opinion death occurred 8t
<br />the lime, date and place and due to the cause(s) stated. (Signature and Title) ...
<br />
<br />2S_ DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />NO
<br />
<br />NOV J 6 2008
<br />
<br />HHS-6111/03 (55061)
<br />
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