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STATE OF NEBRASKA ,I,ei~~' `'"'~ f ; ~
<br />WHEN THIS COPY CARR/ES THE RAISED SEAL OF THE NEBRASKA HEA~HA1A~p~~A'I~F~S&F~l~ S
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIQ~NA~ ~ ~• 4 Mil
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S~iTI~T(C~TIO 1G`'I'L.+l, ~r
<br />THE LEGAL, DEPOSITORY FOR VITAL RECORDS. '. • " ~
<br />~., ,,
<br />DATE OF /SSUANCE ~ ~' _ ` ~'
<br />J' i L`" ..~ ~ ~
<br />TANLEY~. CODS W;r
<br />JUN 2 7 2008 2 0 0 9 o s 9 5 2 ,a'ss~fian~,T STATE R,~'~,ST~ ,.~
<br />LINCOLN, NEBRASKA H,~ALTM,4'Nl~'. AI~k,1~IRi//~S.
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPP~TQ ~ G 7
<br />(_~RTIFI(`_AT~ (1F r1GATW (]] V
<br />% ,.
<br />1. OECEDENT'$-NAME (First, Middle, Last, Sulflx) 2. SEX 3. DATE OF DEATH (Mo., Dey, Yr.)
<br />Lillie Freda Boyle Female ,Tune 17, 2008
<br />4. CITY AND STATE OR TERR170RV, OR FpREIpN COUNTRY OF BIRTH 5a. AGE-Lest Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Wolbach, Nebraska (Yrs.) 92 MOS. DAYS HOURS MINS. November 2$, 1915
<br />7. SOCIAL SECURITY NUMBER ___. 8a. PLACE OF DEATH
<br />~n7~L-LZ13__ HOSPITAL: ^ Inpatient 4IHEB: ~ NursingHOmalLTC ^HospiceFacility
<br />Bb. FACILITY-NAME (ll not Inetitutlen, {}Iva ~trvA1 And nurpber) ~ ^ EtT/0ulpatlent ^ DACedent'a Homa
<br />Good Samaritan $ocietp
<br />Wood River Western Hall County
<br /> ^ t3Da ^ Other(spaciry)
<br />Bc. CITY OR TOWN OF pEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br />Wood River, 68883 Hall
<br />9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Wood River
<br />9d.97REETANDNUMBER ~ 9e. APT. NO Bf.ZIPCODE 9g. INSIDE CITY LIMITS
<br />1401 East 5t. 68883
<br />_ F XI YES ^ No
<br />10a. MARITAL STATUS AT TIME OR pEATH ^ Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, glue maiden name.
<br />^ Married, but separated ~ Widowed Q Divorced ^ Unknown
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />Julius Johnson Carrie Andersen
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a.INFORMANLNAME 14b. RELATIONSHIP TO pECEDENT
<br />(Ves,no,orunk.) No Ruth Ann Fisher
<br />w Daughter
<br />15. METHOD OF D13ROSITION 18a. EMB E -SIGNATU _ m i8b. LIC
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<br />NSE N0. 1 Bc. DATE (Mo., Day, Yr. )
<br />C~eurial ^Doneuon ^
<br />~
<br />1~+ June 21, 2008 _
<br />^Cramation GlEntom6ment 16d.CEMETERY,CREMAT Y OTHER LOCATION CITY/TOWN STATE
<br />^Removal Uothar(spacify) Wood River Cemetery Woad River, Nebraska
<br />_
<br />17e. FUNERAL HOME NAME ANO MAILING AppRESS (Street, City orTown~State) 17b. Zip Code
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE 68801
<br />,. '. 'T A S
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<br />18. PART I. Enter the Cbgjn,gJ,gysllig--diseases, Injuries, or complications••that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without ahowlnq the etiology. DO NOT ABBREVIATE. Enlar only one cause on a line. Add additional Ilnea If necessary, i
<br />IMMEDIATE OAUSE: I onset to death
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<br />IMMEDIATECAU$E(Final (a) ~~ ~ Q ~ ^~_ _. '~+~ ~ ~~~ ~ V ~ ~ ; M a N~ S.
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<br />dlseeseorcondAlonresulllnq DUETp,pRq
<br />I onset to death
<br />N3E0UE CEOF:~
<br />In death) I
<br />5equenllAlly Ilat condltlone, If (b)
<br />I
<br />_ _
<br />any, leedtng fa the cause Meted DUE TO,OR ASACONSEQUENCE OF; ~~~ ~I onset to death
<br />an Ilne a.
<br />I
<br />EnterihaUNDERLYINOCAU5E
<br />(dlseaseorinjurythatlnitiated (c) I
<br />thasvsntsrssultlnglndeeth) DUE TO,ORASACONSEOUENCEOF: ~ I onset to death
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<br />r 18. PART IL OTHER SIGNIFICANT CONDITIONS-Condlllons cornrlbuting to the death but not resulting in the underlying cause given In PART I. 79. wAS MEDICAL EXAMINER
<br />~ OR CORONER CONTACTED?
<br />,~,\ M'o~~'~
<br />P
<br />V ^ YES ~NO
<br />20. IF FEMALE: 21 a. MANNER OF DEATH 21 b.IFTRANSPORTATION INJURY 21c. wAS AN AUTOPSY PERFORMED?
<br />7~-Not pregnant within past year ~7Qaturel ^ Homicide ^ Driver/pperator
<br />^ YES ~ NO
<br />
<br />~
<br />^ Pregnant at time of death ^ Accldent^ Pending Investlgetlon ^ Passenger
<br />s ^ Not pregnant, but pregnant wlthln 42 days of death
<br />Q Suicide ^ Could not be determined ^ Pedestrian 27d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> <] Othar(Specify)
<br />^ Not pregnant, but pregnant a3 days to 1 year before death COMPLETE CAUSE OF DEATH?
<br />
<br />^ Unknown if pregnant wlthln the past year
<br />s
<br />^ YES '~. NO
<br />---22a. DATE OF INJURY (MO., Day, Yr.).
<br />i ~22b. TIME OF INJURY
<br />m 22c. PLACE OF INJURY•At home, farm, street, factory, Attica building, construction site, etc. (Speci}y)
<br />22d.INJURYAT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />^ YES ^ ND
<br />~..
<br />~
<br />STATE ZIP CODE
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT. N0. ~ CITY!lOWN
<br />____~...
<br /> 23a. DATE OF DEATH (Mo., Dey,Yr.) ~~ _~ ~ ~ 24e. DATE SIGNED (MO., Day,Yc) 246.TIME OF DEATH
<br />
<br />'
<br />y H ~ _ ~ 24c, PRONOUNCED DEAD (Mo., Day,Yr.) 24d. TIME PRONOUNCED DEAD
<br />(Mo., Day, Yr.) 23c.TIME OF DEAT
<br />SIGNED
<br />23b, DAT
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<br />' 24a. On the basis of examination and/or investigation, In my opinion death occurred at
<br />P.
<br />23d. To the bast of my knowledge, death occurred el the time, date and place I
<br />~ to the cause(s) stated. (Signature and Title) • ~ ~ o the time, data and place and due to the cause(s) stated. (Signature and Title)
<br /> a~ ~~ nn~ \~ M.p ~ ~ a
<br />25. DID TOBACCO USECONTRIBUTETpTHEDEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />_ ^ VES 0 Q PRpeABLY ^ UNKNOWN _ ^_YES BHA ~ Not Applicable if 26a is NO ^ YE5 NO
<br />27.NAME,TITLEANpADDRESSOFCERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN ORCOUNTVATTORNEY) (Type orPrlnq
<br />,john Cannella M.D. 729 ". Custer Ave , Grand Island, NE. 68803
<br />28a. REGISTRAR'S SIGNATURE 286. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />~. JUN 2 6 2008
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