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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AI~~IvV SERVICES, IT CER7"IFIES
<br />THE BL~LOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITM THE NEBRASKA'S TN~E/U~1DF•HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE WHICH IS THE LEGAL DEPOSITORY FOR V1TALr1F~~R~R~.' ~ ;; : ~ ' d
<br />DATE OF ISSUANCE ~1 ~, q
<br />/~`~ .
<br />STALI(~~Y S. COOP
<br />~luL a e z0~a ~ 2 o i o 0 4 9 0 8 - ,q.~s~TAN~s1~fE.'~2Ei~1ST~-!~; '. ;
<br />DfP ~M~ t:31~ HL~4L~1 ANEj
<br />LINCOLN, NEBRASKA M'trlNi~JN~SERVICES .' ;'~,~
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<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVId $ zr `n , ~~~ !~ ~ r
<br />CERTIFICATE OF D A ~ ~ ` s' ~ ~'~~.''~~~',~ ~`~
<br />1. DECEDENTS-NAME (Pint, Middle, Last, Suftlx) 2. SEX ~A . 3. 0/L OF OEA'(FI ( .,f)~1; Yr.)
<br />~ °'
<br />Walter Ralph Borgmann Male June 28, 2D'i0 '~
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Oe. AGE-Last Birtlaley Ob. UNDER 1 YEAR 6c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yn.) MO& DAYS HpURS MINS.
<br />Longmont, Colorado 76 December 31, 1833
<br />7. $OCU1L SECURITY NUMBER 8e. PLACE OF DEATH
<br />~ 523,,,42_804() HOSPITAL: ®Inpatlent DTHER: ^ Nuninq Hans/LTG ^ Hospice Facility
<br />I" 8b. FACILITY-NAME (If not InsUtutlon, give elnat and number) ^ ER/Outpetiant ^ Oecedent'a Home
<br />Saint Francis Medical Center ^ °~ ^°~°nsp°"r")
<br />ec. GITY OR TOWN OF DEATH (Include Zip Cade) ad. COUNTY pF DEATH
<br />Grand Island 88803 Hall
<br />~ 9a. RESIDENCE$TA7E 96. COUNTY 9c. CITY OR TOWN
<br />a
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<br />~, Nebraska Hall Grand Island
<br />9d. STREET AND NUMBER !M. APT. NO. W. ZIP CpDE flq. INSIDE CITY LIMITS
<br />.e 1315 W. Koenig St. 3 68801 ®Yes ^ No
<br />t0a. MARITAL STATUS AT riME OF DEATH ~ Married ^ Never Married tllb. NAME OF SPOUSE (Pint. Middle, Leet SuPAx) H wife, giw mtiden name.
<br />~ ^ Mardsd,buteaparetad ^ Wldawsd ^ pivorced ^ Unknown
<br />g, Joyce K Stromenger
<br />4 11. FATHER'S-NAME (Pint, Mlddla, Last, aufTx) 12. MOTHER'S-NAME (Flat, Middle, Miltlen Summa)
<br />O
<br />~m Walter H Bor mann Edna Louise Slee
<br />m 13. EVER IN U.S. ARMED FORCES? Give daGs of sarWce N Yas. 14s, INFORMANT-NAME 14b. RELATIONSHIP 7D DECEDENT
<br />4
<br />F- (Yea, No,arUnk.) jljp Jo Ce K Bor mann Wife
<br />79. METHDO OF o1SPOSIriON iea. EMBALMER-SIGNATURE 166. LICt=NSE NO. 18c. DATE (Mo., Day, Yr.)
<br />©°1"a' ©oonaa°" Not Embalmed June 27, 2010
<br />~cremetl°n ^Emomemerd
<br />^Ran°Val ^oenegep.elry) 16d. CEMETERY, CREMATORY pR OTHER LOCAriON CITYITOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a..FUNERAL HOME NAME AND MAILING ApORE$8 (Street, Clly or Town, Stets) 77b. Zlp Cads
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />+!. PMT I. Enx the ehWn ~yvenm - diaaa, in)udea, nr c°mpliutiona-wt °inuryy quad ma °wtb. no No7 emer unninu wame wen as car°iac amn, ~ APPROXIMATE INTERVAL
<br />nepirn°ry arose, or vamdcuur aemltlion without allowing ma Nf Wogy. DD NOT AB9REVIATE. E~Nr only a~M sear an a line. Add atldnioal lines k mceaxry.
<br />IMMEDU\TE CAUSE: `.., ~ /~ ;onset to death
<br />disease yr cgrtdiUOn(neultlng a) C-/l J"~~ I (] P Vi..r!tl~(Jr Y YnF-~ f~ ~rj
<br />In death)
<br />DUE TO, OR A5 A CONSEQUENCE OF: ;onset to death
<br />$egwntlally Ilat corWitlana, R b) rj ~ S n ~~ L~
<br />any, iaading W the cans listed 1'~' r
<br />on Iina a. DUE TO, OR A$ A CONSEQUENCE OF: h' L ~ onset to death
<br />Elder tfw UNDERLYINr3 CAUSE c) 5 ~C 5 I S I ~ ' Y ~•r G~ (JN I r\
<br />(disease ar injury that Inidatsd
<br />the evaMe reeultlng in death) DUE TO, OR AS A CDNSEQUENCE OF: ~ onset to death
<br />LAST
<br />d, ~sc.N~r i G ~, ran, anti ro P~~7
<br />19. PART II.OTHER SIGNIFICANT C.ONDITK)NSConditlons conMbutlng to the death but not nwltlnq In the undaHying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />~ It/l ~ ~ `j SE ~'(~ ^ YES ®/No
<br />a
<br />W 20. IF FEMALE: 21st. MANNER OF DEATH 216. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />^ Nat pregnant within past year ~Natunl ^ Womicide ^ DdveNOpentar ^ YES [~Jp
<br />^ Ptepnent at tlms of death ^ Accident ^ Pending Irweetigatlon ^ Peasenger
<br />tJ Not non but n hoot wltltln 42 da s tN death 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />^ Preq 4 P q Y ^ Suicide ^ Could not be determined (] Pedestrian 70 COMPLETE CAUSE OF DEATH?
<br />^ Not pregnant, out pregnant 43 days to 1 year before death ^ OtMr (Spacffy) ^ YES ^ NO '
<br />^ Unknown n pragrwtt within the past year
<br />m
<br />~.
<br />a 22a, DATE OF INJURY (Mo., Day, Yc) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At honor, farm, atrwt, factory, office building, constructlon alts, etc. ($pactfy-
<br />U yn
<br />m
<br />m 22d. INJURY AT WORK? 22e. DESCRIBE MOW INJURY OCCURRED
<br />O
<br />t-' ^ YES ^ NO
<br />22f. LOCATION OF INJURY - STREET A NUMBER, APT. NO. CITYITOWN S7AYE ZIP CODE
<br />23e. GATE OF DEATH (Mv., Day, Yr.) Z 24a. DATE SIGNED (Mo., Day, Yr.) 246. TIME OF DEATH
<br />3' W D 6 - Z(~ -- Zb l O SSS~11t V~1 t~~ m
<br />~ 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ } Q 24c. PRONOUNCED pEAD (MV•, Day, Yr.) 24d, TIME PRONOUNGED DEAD
<br />~~o b6 -- 2 -DID Z-' S~ pm E~a~ m
<br />m °~ 23d. Ta the bas! of my knowledge, death occurred M the dme, data and place ~ y~,l Z SAa. On the Gaels of examinatlon andlar invastlgatlon, in my opinion death accumd
<br />O W and due to the cause(s) stated. (Signature end Title) ~ z oo~ at the tlme, data arM place and due to tlta uuse(e) afated. ($Igneture pod Title)
<br />O b-• t3
<br />26. DID TOBACCO USE CONT 6UTE Tp THE DEATHT 28a. HAS ORGAN OR TISSUE NATION BEEN CONSIDERED? 26b. WAS GONSENT GRANTED?
<br />© YE$ ^ NO ~PRQBABLY ^ UNKNQWN ^ YES m NO Not Applicabl° N Z9a is NO ©Y$$ ^ NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHY$K:WN pR GOUNTY ATTORNEY) (Type or Pdrd)
<br />~~->/1`KA R-~ S~L~N( M.D. $00 N. Al ha St Grand Island NE 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yc)
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