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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL7t~k~{Nl~ t~f,~Xl At SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBkA$.1$L~P,~Z'~M~JV~"X~ HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WMICH IS THE LEGAL DEPOSITORY FOay t~ITAL~ ~t~~ ~ ~ > ~ ;, ti , ; ;
<br />F I ANCE ~'
<br />DATE O SSU ~~/~, , ~'r.
<br />JUL 2 4 2009 sr`aINLEY~~. ~p ~~~,- •;
<br />2 U l 0 0 0 4 "y 5 As~7~rA,e~..~~~~rSTR~-R'
<br />DE8e4RTMEl~IT C?F;?,~dFAL~'M~;4dV~•''
<br />LINCOLN, NEBRASKA IiLlt~~liV $~ERVICES •' ,;'.' ,`
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVtCES~ Z F ~ ,~~\~`,
<br />t .FRTIFIL:ATF n~ f]I~ATH '' ~" " ~ ~'...
<br />1.DECEDENT'$-NAME (FIre6 Mlddle, Laat, St1TRx) 2.5EX 3. d EATH Mo.,Day,Yr.)
<br />Dar I Dean Bockmann Male June 3, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE-Last Birthday 5b. UNDER 1 YEAR 8c. UNDER 1 DAY 8. DATE OF 91RTH (Mo., Day, Yc)
<br /> (Yrs.) MOS. DAYS HOURS MIN5.
<br />Grand Island, Nebraska 67 February 15, 1942
<br />7. SOCIAL SECURITY NUMBER ea. PLACE OF pEATH
<br />507-54-4865 HOSPITAL: ©Inpstlent OTHER: ^ Nunlnq HomalLTC ©HoapiCe Facility
<br />Bb, FACILITY-NAME pf not Instltutlon, glue street end number) ^ ER/Outpatlent .,~Decadent9 Nome
<br /> ^ DOA ~Other(SpaclfY) Farm
<br />6360 5. HWy 281
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) ed. COUNTY OF DEATH
<br />Grand I$land 68803 Hall
<br />9a. RESIDENCE-STATE 8b. COUNTY Bc. CITY pR TOWN
<br />Nebraska Hall Grand Island
<br />9d. STREET AND NUMBER 9e. APT. Nq. iN. ZIP COpE Bg. INSIDE CITY LIMITS
<br />6360 S. H 281 68$D3 ^vea ®No
<br />10e. MARITAL STATUS AT TIME OF DEATH ®Marrled ^ Never Maenad lob. NAME OF SPOUSE (Fine, Mlddle, Loal, SufYx) H wife, glue maiden name.
<br />^ Married, but separahd [,] Widowed ^ Divorced ^ Unknown Karen Diane Fagot
<br />71. FATHER'S-NAME (FIre6 Mlddle, Last, StlMix) 12. MOTHER'S-NAME (Pint, Mlddle, Malden Sumama)
<br />Theodore Bockmann Iola En el
<br />13. EVER IN U.g. ARMED FORCE97 Glva dates of service Ir Yea. 14a. INFORMANT-NAME 146, RELATIpNSHIP TO DECEDENT
<br />(vea, Na, ar unk.) Yes 05/13/1968-07!03/1969 Diane Bockmann Wife
<br />16. METHOD OF DISPOSITION 18a. EM MER-SIGNATURE i8b. LICENSE NO. 16c. DATE (Mo., pay, Yr.)
<br />®eaeai ^bonauon l,y~ ~ ~ June 6, 2009
<br />^cmmedon ^emomhmant
<br />^ Ramovai ^OtnerySpeclry)
<br />18d. C METERY, CREMATORY OR OTHER LOCH ON CITYITOWN STATE
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MpILINp ADDRESS (Street, Clty ar Town, State) 176. Zlp Cade
<br />All Faiths Funeral Home, 2929 S. Lpcust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and examples
<br />10. PART I. Enter the chain orawets - diseases, injuries, or oompllcatlans-that direcgy caused tree eeatn. Do No7 smn nrmhlal avema such as umuc sense, 1 APPROXIMATE INTERVAL
<br />naplrHOry amn, or wntdcuur tlhdllatlon without shvwinp tM Nlology. DO NOT ABBREVIATE. Enter only one cauu on a nna. Add addMonel lines N mce..ary, 1
<br />IMMEDIATE CAUSE: ~ enaet t0 death
<br />IMMEDIATE CAUSE (Final
<br />1
<br />diseaaeorconditionresulting a) Accident while ridin a horse W unknown t e of in title
<br />In death)
<br />DUE Tp, OR AS A CONSEOUENGE oF: ~ onset eo death
<br />Saquantially Ilat coneltiana, If ~
<br />b)
<br />any, leading to the cause hated
<br />At t em
<br />on Iina a. pUE TO, OR AS A CONSEQUENCE OF: ~ anaet to death
<br />1
<br />
<br />1
<br />Enter the UNDERLYING CAUSE c) 1
<br />i
<br />(disease or Injury that Inltlated
<br />the events reaulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LASr ;
<br />1
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<br />18. PART II. OTHER SIGNIFICANT CONpITIONB-Conditlons contributing to the death but not reaulting in the undertying cause given In PART I. 18. WAS MEpICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> YE$ ^ NO
<br />20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFgRMED7
<br />^ Nat pregnant wiThln past year ^ Natural ^ Homicide ©pdver/Operator ^ YES ~ NO
<br />^ Pregnant at lime or death ~Accldent ^ Pending Imeatlgatlan ~] Paraanger 27 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />^ Not pregnant, but pregnant within 42 Jaya of death ©Suicide ^ Could not be determined [] Pedestrian TD COMPLETE CAUSE OF DEATH?
<br />^ Not pregnant, but pregnant 43 days to 1 year before death I$l Dther (Specify) ^ yEg ®NO
<br />^UnknownlTprdgnantwithinthepastyear horse rider
<br />22a. DATE OF INJURY (Mo., Day, Yt:) ,22eb~FMe ~lltNJURY sec. PLACE OFINJURY-At home, term, street, rectory, omce 6ullding, construction site, etc. (Specity)
<br />June 3, 2009 am & 12
<br />std. INJURY AT WDRK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />^vES ®NO
<br /> Accident while tr in to break. a horse.
<br />22f. LOCATION OF INJURY -STREET & NUMBER, APT. NO. CITYII"OWN STATE ZIP CODE
<br />`6360 South HCdY 28.1, Grand Island, NE 688p3
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 2Aa. DATE SIGNED (Mo., pay, Yc) B~W~~A DEATH
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<br />~ June 9 2009 nl
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<br />W 23b. DATE SIGNED (Mo„ Day, Yr.)
<br />~ 23c. TIME OF DEATH ~ ~ t? 24c. PRONOUNCEp pFAD (Mo., gay, Yr.)
<br />a 24d. TIME PRONOUNCED pEAD
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<br />°' i June 3, 2009
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<br />g 23d. Ta the beat or my knowledge, death occurred at eha time, date and place
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<br />26. DID TpaAGCO U$E CgNTR19UTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DO ATION BEEN C D? 28b. WAS CONSENT GRANTED?
<br />^ YE$ ^ Np Q PROBABLY UNKNOWN ^ YES ~ NO Nat Applicable Ii 28a la NO ^ Y$$ ^ NO
<br />27. NAME, TITLE AND ADDREgB OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or PAnt)
<br />Aaron Kung, Deputy Hall Co1!>n1t~ .>~rt~Corney, 231 South Locust 5t. Grand Island NE 68801
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REpI$TRAR (Ma., Day, Yr.)
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<br />~~ 19 2009
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