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�' ` STATE OF NEBRASKA
<br />WHEN 7`HIS COPY CARRIES THE RAISFD SEA� OF THE NEBRASKA DEPARTMENT OF HEALTM ANl�fl�tl�/��U,SERVICE,S,'IT'CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBI?A5fC�1��E/� R�T�I�C AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR.11�7'`�At�,le "�'' .,, ��:_
<br />DATE OF ISSUANCE
<br />10/14/2010 2p�,�p�782
<br />LINCOLN, MEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN
<br />AG'�T�C't/'�AT'L" AI� �1CATlJ
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<br />1. DECEDENTS-NAME (First, Middle, Last, Suftix) Z. SIX ' e 73: �1tTE OF ��ATW-•(Mo., Day, Yr.)
<br />Florence Bourg Female �� ,October 6; 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Lasf Birthday b. UNDER 1 YEAR 5c. UNDER 1, DAY. 8. DATE OF B1RTH (Mo., Day, Yr.)
<br />(Y�J MOS. DAYS HOURS MIN3., ; .;_
<br />England 90 May 1, 1920
<br />7. SOCIAL SECUWTY NUMBER 8a. PLACE OF DEATH
<br />50&12-0480 O P AL � Inpadent OTHER � Nursing Home/LTC � Hoaplce Fac11Hy
<br />8b. FACILITY-NAME (If not Institution, give street and number) � ERiOutpatlerrt ❑ Decederrt's Home
<br />�
<br />�' Goad Sam. Society-Hastings Village, Perkins Pav. ❑ noa ❑ on,er �specKy�
<br />� 8c. Cfi'Y OR TOWN OF pEATH (Include 2ip Code) 8d. COUNTY OF DEATH
<br />c Hastings 68902 Adams
<br />� 8a. RESIDENCE-STATE 8b. COUNTY 8a CITY OR TOWN
<br />Z Nebraska Adams Hastings
<br />LL 9d. STREET AND NUMBER 8e. APT. NO. 8i. ZIP CODE 8g. INSIDE CITY LIMITS
<br />�, 300 S 1st Avenue 68901 � res ❑ No
<br />' 10a. MARITAL STATUS AT TIME OF DEATH Married
<br />� � ❑ Never AAarriad 10b. NAME OF SPOUSE (First, MUddle, Last, SufH�c) It wHe, 8we ma�den name
<br />��❑ iMamea, butsepa�aced ❑ uwdowed ❑ n�vorcea ❑ uNcnown Gerald W Bourg
<br />� 17. FATHER'S-NAME (First, Middle, Last, Suftiz) 12. MOTHER'S-NAME (First, Mlddle, Maiden Sumame)
<br />� Isaac Lawson Mary Banks
<br />°' 73. EVER IN U.S. ARMED FORCES? Gtve dates of service H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ (res, No, or unic.► No Gerald W Bourg Husband
<br />,� 75. METHOD OF DISPOSITION 76a. EMBALMERSIGNATURE 16b. LICENSE NO. 78c. DATE (Mo., Day, Yr.)
<br />F � Burial ❑ Donatlon
<br />James M. McLaughtin 951 October 12, 2010
<br />❑ CremaUOn ❑ EnWmbment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br />❑ Removai ❑ Other (Specify) Parkview Cemetery Hastlngs Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State) 77b. Zip Code
<br />Livingston-BuUer-Volland Funeral Home, 1225 N. Elm, Has�ngs, Nebraska 68901
<br />CAUSE OF DEA See tnstructions and exam les
<br />18. PART I. Eirter the chatn oi eve� Kliseasas, Iryuriae, or compltpHOnsdhat direetly caueed the death. DO NOT errter tarminal eveMa such as cardiaC ertest, �, ; APPROXIN44TE INTERVAL
<br />resplratory arrest, orreMricutar flbrillation without ehowl� the ettology. DO NOT ABBREVIAT& Fr�fer only orta cause on a Il�re. Add additlonal Ilnea IT �re�ry.
<br />IMMEDIATE CAUSE: ; o�et to death
<br />IMMEDIATECAUSE{Flnal e)Congestive Heart Failure ; 4 Weeks
<br />disease or condtdon reauitlng
<br />fn death) DUE TO, OR AS A CONSEQUENCE OF: C onset to death
<br />SequeMlalty Ilat conaltlone, H b) .
<br />arry, leadtng to tha ceuse ttated -
<br />on Ime a DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />�rtire UNDERLYINO CAUSE ��
<br />(dlseaw or In1uN �et IniGated -
<br />ure eve"te ^ae'dtl"B m deazF'� DUE TO, OR AS A CONSEQUENC� OF: : onset to death
<br />� d) i
<br />18. PART U. OTHER SIGNIFICANT CONDITIONS-CorWitiore contributing to tha death but not resuldng in the undariying cause glven in PART I. 19. WAS MEDICAL EXANONER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W O. IF FEMALE: 21a. MAPINER OF DEATH 21b. IF TRANSPORTATION INJUR 21a WAS AN AUTOPSY PERFORMED?
<br />�
<br />� � Not praB���n pastyear � NaWral � Homiclda � DriveNOperaMr
<br />� � PreB� et tlme of death � pccitleM � PBndi� ImeaUgaqon ❑ Pewenger ❑�$ � NO
<br />� � nWt pre¢nant, 6ut pregnaM w�tiun a2 days ot death � Pedesulan 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />a ❑ Sutc�de � Cowtl rtot be detemmneu TO COMPLETE CAUSE OF DEATH?
<br />� NM pree�a�t. but pregnaM 49 days to 1 year 6efora death � Other (Speciy)
<br />� �. Q Unlmawn it P�e�e vrlthin the Pae� Year � ❑ YES . ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, offlce bullding, conatrucUon atte, etc. (Specify)
<br />$
<br />� 22d. INJURY AT WORK4 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ YES Q Id0
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITYlfOWN 3TATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.S October 6, 2010 ,� � �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEAT�I ���� 24e. PRONOUNCED DEAD (Mo., Day, Yr.! 24d. TIME PRONOUN6ED DEAD
<br />�' Z OCtober 11, 2010 06:30 PM a a
<br />$�� . To tha best of my Imowledge, death occurtetl et the 8ma, date and piace $��� 24e. On the basis M examinatlon amllor InveatlgaGon, In
<br />�� antl tlue ro the muae(e) stated. (Slgnature and 7fUe) � $ o O my oPlnlon death oxurreU at
<br />F the Bme, date and place antl tlue M th0 cause{s) etated. (S�gnature and TfGe)
<br />DBVId Little, MD '' $ o
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicabte H 28a Is NO ❑ YES ❑ NO
<br />. R AND DRE IFIER (PHYSIC , S C , O 0 P OR OUNTY A E1n (Type or Prir�
<br />David LittJe, MD, 2115 N Kansas Avenue, Has�ngs, Nebraska, 68901
<br />28a. REGISTRAR'S SIGNATURE � I 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />October 12, 2010
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