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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF TNE NEBRASKA DEPARTMENT OF HEALTH AIVD NUMAN SERVICES,17 CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPA&.TPrE�IT C�F HEALTH AND
<br />HUMAN SEItVICES, VITAL RECORDS OFFICE, WHICH ZS THE LEGAL DEPOSITORY FOR VITAL RECDI�DS � a;•? ��;i }
<br />DATE OF ISSUANCE ��/�a���� � � ,
<br />�� ' � `',
<br />STAlVLE`?' S� CQ�PER ��` ' ��
<br />05/16/2011 . as5z5rAi�r�rA� €�isl�aR � "e; ,
<br />� U �.1 U 6 7 � 8 ���a��-���,- o����J� ' �`� ��. -
<br />LINCOLN, NEBRASKA hfUNtA�i �'�i.�1fl�_ _
<br />,Y e � k _
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICESr �� ^�!; '�°'
<br />CERTIFICATE OF DEATH �,:�-�b . �k. �' �"� d'�
<br />��
<br />1. DECEDENTS-NAME (Flrst, Middle, Last, Sufflx) 2. SDC �� : Df�T DFATH lMo., @aY, Yr.) ;
<br />Louis Leavem Bolles Male �F "lVI�y4;'2U'�1 =�
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF B1RTH 5a. AGE - Last Birthday b. UNDER 1 YEAR 5e. UNDER 1 DAY -, 8. DATE OF BIRTW (Mo„ Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS IU�NS. �
<br />Wood River, Nebraska 79 September 8, 1931
<br />7. 80CUU. SECURITY NUMBER 8a. PLACE OF DEATH
<br />507-36-3277 HOSPRAL � InpaUent OTHER ❑ Nuraing HomeILTC � Hospiee Faellity
<br />8b. FACWi'Y-NAME (It not Instlhrtion, Bfve street ami numbery � ER/OutpatleM � DeeedenYs Home
<br />�
<br />� 3007 Orleans Dr. ❑ noa ❑ o�ner �sPac�ty�
<br />�
<br />� 8e. CITY OR TOVYN OF DEATH pnelude 21p Code) Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />�7 8d. STREET AND NUMBER 9e. APT. NO. 9t. ZIP CODE 8g. INSIDE CITY LINOTS
<br />� 3007 Orleans Dr. 68803 � r�s ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Ma►rled ❑ Never Marrled 10b. NAME OF SPOUSE (Firet, Middle, Last, SuHtu) N wife, 8�e rt�a�den rmme
<br />€ ❑ iwarr�ea, nut separacea ❑ wnaowea ❑ Divorced ❑ unicnown Norma Jean Kingsley
<br />� 11. FATHER'S-NAME (Fl�st, IVOddta, Last, SuHiz) 12. MOTHER'S-NAME (FUat, Mlddle, Maiden Suma�rte)
<br />� Francts Homer Bolles Altce Ooley
<br />�' 13. EVER IN U.S. ARMED FORCES? Glve dates M service H Yea. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />s (Yes, No, or un�c.) Yes 06/30/1951-06/27/1955 Norma Jean Bolles Wife
<br />,$ 1S. METHOD OF DISPOSITION 16a EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo, Day, Yr.)
<br />F ❑ Burial ❑ Dormflon
<br />Not Embalmed May 7, 2U11
<br />� CremaUon ❑ Entombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />���� ��� Central Nebraska Crematlon Senric�s Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CHy or Town, Sffite) 77b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF D�AT 5ee instructions an exam les
<br />1& PART L EMer the chaln of eve��lsea�e, InJuHes, or compllcatlo�rthat d6eWy cauaetl the deffih. DO NOT eirter terminal evettte such � cardiac arteet, � APPROXIMATE INTERVAL
<br />resplratory arrest, or veMricuiar flbNilatlon wfthout shoMng the etloto0y. DO NOT ABBREVIATE. Fr�ter ony o�re cauae on a Ihre. Add addtdonal Ihree H neceasary.
<br />IMMEDU►TE CAUSE: ; orreat to death
<br />immmwrecnuse� a)Sulcide � Immediate
<br />dieease or conditlon resulting
<br />1° �� DUE TO, OR AS A CONSEQUENCE OF: � o�et to death
<br />s��,ro�n„ �res �,�mu,,,,, u b) Gun Shot To The Head � Immediate
<br />anr, ieeaure to me wuse �sea
<br />on mre a DUE TO, OR AS A CONSEGUENCE OF: : orreet to death
<br />EMertlre UNDERLYWG CAl1SE G � '
<br />(dieease or injury that initiated
<br />the eveMe resultlnp In death) DUE TO, OR AS A CON3EQUENCE OF: � oriset to death
<br />� d)
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS-Conditlo� cor�trlbutlng to the death but not resufHrtg In the urMerlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED4
<br />� � YES ❑ NO
<br />W 20. IF FEMALE: 27a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />�
<br />� � Not Pregimnt wfthln past year � Naturel � Homieltle � DrivaAOperaWr �� � NO
<br />W PregnaM at tUm M death Passenger
<br />V � Acdderrt � Pendl� Imestigetlon
<br />� � Not pregnanf, bu[ PreB� Wi��'� deYe of death � ❑ � aeaesman 21d.T0 OMPLETE CAUSE OF DEA���
<br />smwae coma �rot ne aetarmt�rea
<br />� Not PreBnant, 6ttt P� 49 deye to 1 yeer bBfO�e tleatM � 08tet (SpeCHy) ❑ ❑
<br />m � Unknown H PreBnarrt wfth�n tlre P� Year
<br />YES NO
<br />F 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY At home, tarm, atreet, factory, office buUdl�, wr�struction sfte, ete. (Spectiy)
<br />e� May 4, 2011 07:00 AM Home
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F Self inflicted gun shot to head.
<br />❑ vES � No
<br />22f. LOCATION OF WJURY - STREET 8 NUMBER, APT.NO. CITYROWN STATE ZIP CODE
<br />3007 Orleans Drive, Grand Island Nebraska 68801
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />` S B�� May 10, 2011 Approx 07:00 AM
<br />� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEA7H ��� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$ o E �<� Ma 4, 2011 09:28 AM
<br />,� . To Ure baet of my Imowtadge. death ocwrted at Me Ume, date end ptaee $ ��
<br />24e.On the basis otexamination anNOr Imeatigatlon, ln my opWon deeth oaurtetl et
<br />�- ana aue w tne cauae�s� sraeea. �s�¢nawwre a� ntte) � � tne ame. aam ana ptaere ana aue so ure cauae�sl arama. �s�gnamre ena nuel
<br />'" � ~$$ Robert Cashoili, Hall Deputy County Attomey
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDI 26b. WAS CONSENT GRANTED?
<br />❑ YES � NO � PROBABLY ❑ UNKNOWN � YES � NO Not Applleable I} 28a is NO ❑ YES ❑ NO
<br />2. NAME, ITL D ADDRESS OF ERTIFIER PHY 1 IAN, HYSIC ASSISTANT, C RONER PHY O C UNTY A (Type or Prl�rt)
<br />Robert Cashoill, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE '�• �i 286. DATE FlLED BY REGISTRAR (Mo., Day, YrJ
<br />May 10, 2011
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