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{ 2Q1008�28
<br />S7f17E OF NEBRASKA-DEPARTMENT bF HEAL7H ANb HUMAN S�I�VICES FINANCE AND SUPPORT r�.,r
<br />GERtI�ICA7'� OF DEATH t��J�,Ua3
<br />1. UECE�ENT'S-NAME (First, Middle, lael, Sultlx) 2. 5EX 3. DATE OF PEATH (Mo., Aay, Vr.)
<br />Ruth Alleen Bvsle Female Apr 25, 2009
<br />4. CITY AND STAT� OF 7EppITOpY, pp rORE1GN COUNTRY OF BIHTH 5a. AGE-Last Blrlhday 5b. UNDER i YEAR 5c. UNpER 1 dAY mm 6. DATE OF BIR7H (Mo., Dey, Yr.)
<br />�Yrs.) MOS, tiAY5 � HOURB T MINB.
<br />Brush,.Colorado. , 85 . Aug 13, 1923 .,
<br />7. SOCIAI 3ECURITY NUMBER � Be. PLACE OF OFATH
<br />507- 28-763d HQSPLY9L: G Inpa11�4� Q11� . �d"�tUrsing Hame/LTC ❑ Wosplce Facllity
<br />8b. FACILITY•NAMF (11 nol Insllfution, give straet and number) �� �
<br />❑ EH/tlutpallent ❑ �ecedenl's Home
<br />Gaod Samaritan Center
<br />1285G Deauville Dr d ooa U Other�5peclly)
<br />Bc. CI7Y OFI TOWN OF �EATH (Include Zlp Code) Bd. COUNTY OF b�ATH
<br />Omaha 58137 Douglas
<br />8a. NESIbENCE-57ATE mm 9b. COUNTY Bc. CITY OR TOWN � ��
<br />Neb�aska Hall Grand Island
<br />9d.57'REETAND NUMBEH ������ 8e. AP7. NO 91. ZIP CODE � 9g. INSIDE CITY IIMITS
<br />1515 W . 1st. St. 68801 [�ves ❑ No
<br />10e. MARITAL 6TATU5 A77iME OF pEATH Merrled C7 Never Merrled t06. NAME OF 9POU3E (Flral, Mlddle, Lnsi, 9ulliz)11 wl1e, glve melden neme.
<br />d Merrled, bul separated ❑ Widowed t] �Ivorced ta unk�oWn ,�� � Dr. W arren 8osfey�� �� � ���
<br />11. FA7HEp'B•NAME (Flrel, ^� Middle, Lgal, Suflix) 12. MOTHER'5-NAME (Flret, Middle, Maiden 8urname)
<br />John� Dorothy James .. __.._ _�..____..
<br />13. EVER IN U.&. AflMEP FORCE87 pive dales al aervlce 11 yea. 14a. INFORMANT•NAME 1 Ab. RELATION5HIF ip DECE�ENT
<br />�vaa, no, or unk.) No Dr. Warren Bosley Husband
<br />15. METHDO OF �I5P051710N 18a. EMB LME -� URE 18b. LICENSE NO. 18c. DATE (Mo., Oay. Vr. �
<br />G?�ur�a� U Donation �. W � V T . ._. ���� 4/30/2009
<br />❑ Creroellon U Entombmenl � 16d. CEMETERY, CREMATORY OR OTHEFl LOCATION CITY /TOWN 6TA7E
<br />C�Removal rao�na�is � Palisade Gemete Palisa NE �
<br />17a. FUNERA1.410ME NAM�hNn MAILUJ� Ad�RESS (Slreet, Cl�yorTown, Slale) 17b. Zip Code
<br />coon�
<br />1B. PAR7 I. Enler Ihe c11Aln of aventa••diseases, In�urles, ar camplicellons--thel direclly caused the daelh. DO NOT enler terminal avenle euch as cerdiac arre8t, � APPRtlXIMATE IN7ERVAL
<br />resplralory arresl, or venlricular 116rlllalian wllhoul ahowing the etlology. PO NOT ABBHEVIA7�. �nter only ane ceuse an e Ilne. Add eddlllnnel Ilnee II necessary. � .
<br />IMMEDIATECAU6E: � onSellodeeth
<br />I
<br />y � p � � �/�/,� I
<br />IMMF�IA7�CAl15E(Flnel � fl) !IC-1�1.1/1�� ��'L I
<br />dlseaeeorcondNnnresulling OUE O, OR AS A CDNSEqUENCE pF: � I onset lo deelh
<br />�n dselh) I
<br />�
<br />8equentlelly Ilsl condltlone,ll �') �
<br />eny,leadingtolhecaueellated ""'�bUpTO,qRASACON5E0UENCEOF: � � I onBettodBath
<br />.....onllnua..-.. -- -..... ._.,_._.,...v....._�-..,.-.�--.-_.-�,,,�.-...._ . . .. . � ...
<br />w...... ...__. .. _. . ._.. . � . . . ..
<br />Enlerlhe11N6EpLYINQCAU5E � �
<br />(dlee�eeorin�urythellnitieted (�) I
<br />IheavenisreeuMingindeelh� pUETQORASACON$EpUENCEtlF: � ���� � onsellodeelh
<br />�� I
<br />(d) �
<br />.-_....�___...,..��_ ...................._...__ �.__ -_
<br />19. pAqT II.OTHEp SIQNIFICANT CONDITIONS•Cpndqlpna conlrl6uUng to Ihe deelh bul not raeulling In Ihe underlying ceuse gWen In PART I. 1B. WAS MEDIGAI EXAMINEq
<br />e,/ � OR CORONER CONTACTED7
<br />� �I XL U��� �G�Y/!�N/6�`"` � ��7� �,�. I��J+�'�`�" ❑ YES � NO
<br />20. IF FEMALE: ��� �� Y 21�. MANNER PF OEATH 216. IF THAN5PORTATION INJl1RY 21c. WAS AN AUTOPSY PERFOfiMED7
<br />� Nol pregirenl w11hln pnsl year
<br />� �NaWrel ❑Homlclde I..�ptivedOperelor � yE9 '�NO
<br />� Pregnent el tlme of daath u Accldenl� Panding Inveellgntlon � Paesenger -
<br />I� Nol pregnenf, but prngnant within 42 days ol deeth � � Pedesirlan 21d. WERE AUTOPSY FINOIN63 AVAILABLE TO
<br />� sulclde � Could not be determinaA � p�her ($pacqy) '
<br />C] Not pregnanl, 6u1 pregnant A3 days lo 1 yanr belore dealh COMPlE7E CAIISE pF pEA7H7
<br />� Unhnown If pragnanl wllhin Ihe pesl yeer ❑ YE5 Gl NO
<br />22a. oATE OF INJURY (Mo., �ey, Yr.) 22b. TIME 0� INJURV 22c. PI.ACE QF INJURvAI bome, farm, slreel, lectory, vllice bulld�ng, construcllon alle, eic. (Spaclly) ��� 1.
<br />m
<br />22d. INJURV AT WORK7 22e. bEBCRIBE HOW INJURY OCCURRE�
<br />C] YES [] NO ,
<br />22L LOCp710N qF INJURY • 97t�EET R NUMBER, APT. NO. � � T CfTVl�OWN � T^T SIME 21P COOE
<br />.. . , �::,�,
<br />��--._............-23a.0AT�E0F � ,.. ,�. . .- _�..._.... ._.._..._.._.....,.-----�._.........._.......�_ ............. .______
<br />� p T�i ( p., psy, Y'.) , �� �� 24e. DATE 51GNED (Mo., �ay, Yr.) 24b. TIME OF �EATM
<br />_ ..
<br />�'� .' ., 1'?� ° � S'c�x ...W_ �_ ------m�-.-. m -
<br />s _� .�.�._._ .�:�-�.. � � ,_-..�. , ... - _ ..�. � _ �
<br />�� 23h UA7E 84ONE ��Ma., Ddy Yr. ��� � 23C.TIME pF �EA�H�., �� 24c. PflONOUNCED OEAO (Ma., Dey, Yc) 24d. TIME PRONOUNCE� dEAd
<br />�� �` � r � � � m &� m
<br />m
<br />° � 23d,%'o Iha he510l my kr�ow Ad e, deetN occurl'�d e Ipe Ilme, dele end plece w 24e. On Ihe 6esle ol exeminetlon andlor Invesllgallon, In my opinlon deelh nccurred at
<br />�� ' ar�d e Io Ih� ceu�e�'s) si"afe netur 4 741e j•� �� v �he Ilme, dalg and plece end due to Ihe ceuse�s) sleled. (6lgnalure end Tltla ��
<br />a ��� f � � � �
<br />25. DIOTOBACW USE CQNTRI8U7EtOtHE b�1�THV'� ;.,; `� �� 26e. HA$ OptlAN tlF1713SUE bONAtIpN 9EEN CtlN$IpEpEp? 286. WA3 CONSEN7 ORANTED7 .
<br />❑ YE9 ; �.,NO;�i�"FR B��'� ��l� U K�yOW�V , f, YE9 � NO Nat Appllcable 1128e la NO Q YE5 ❑ NO
<br />_..�___�_ _. a�_ _.t..._
<br />P7. NAM TL AN�OQRE�5 D�C TIFIER � VSIC�IAN, CORONER'S PFIY51 N OR OUNTY ATTORNEV) pe or Print)
<br />�r � 3 � 3 �� �� �� �� �;
<br />2Ba.pEqIS7RAti'S,SIGNATURE ' �+ � 29h. pATE FIIEp 9v qE0I5TRAR (Mo., Day, Y�.)
<br />� . �, � ':�;:��� V � 4/M�i �YU U � CfAl.7
<br />This cerli�es this docurnent to be a true copy of an original record on file with Vital 5tatistics, Douglas County
<br />Health Dept., Omaha, Nebraska. CertiCed copies an��st l�ave a raised seal in the area to the left. Reproductions
<br />of this gree�� certificale are i�ot legal copies.
<br />���-�^�'`~" ""�.�'� �,,,*
<br />Date Issued: �Y � ZOp9 Re�istrar: ""`
<br />. C.� tr�"�
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