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STATE OF NEBRASKA
<br />. WHEW THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT C
<br />� THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE 1
<br />HUMAN SERVICES, VI7"AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY
<br />DATE OF ISSUANCE ,
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<br />LINCOLN, NEBRASKA
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<br />SSTSF'Al�IT. �'�"�V",1'E REGISTI�4R ;:� r w ' , �
<br />EP�ARFMENT QF HEALTH AND •y°`, , , ' �
<br />'UMAM S�'Rlf�'�ES : �
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<br />CERTIFICATE OF DEATH `' '�"•' ��" '`
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<br />1. DECEDENT'3-NAME (Ftrst, Middle, Last, Suffbc) 2. SIX 3: Dli'tEQF DEATH (Mb„ Day, Yr.)
<br />Diane Kay 8ogner Female Nov�'rtiber�l4; 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Blrthday b. UNDER 1 YEAR Se. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day; Yr.)
<br />(Y►s•) MOS. DAYS HOURS MINS.
<br />Cedar Rapids, Nebraska 64 April 22, 7945
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />507-5&0871 OH SPITAI. ❑ InpaUeM OTHER ❑ Nuraing Home/LTC � Hosplee Faellily
<br />8b. FACILITY•NAME (H not I�tlhrtlon, gbe street and eumher)
<br />� � ER/OutpaUeM ❑ Decedent's Home
<br />� Saint Francis Medical Center ❑ �A ❑ ��►1sa�r1
<br />�
<br />� 8e. CffY OR TOWN OF DEATH pnclude Zip Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 � Hall
<br />� 8a. RESIDENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER 9e. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIIWTS
<br />�, 309 E. 8th St. 68801 � rES ❑ No
<br />a 10a. MARITAL STATUS AT TIME OF DEATH Manted
<br />� � ❑ Never Nlarrled 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wHe, give maiden name
<br />� ❑ Marrled, but separated ❑ Wldowed ❑ Divorced ❑ urumown Kenneth Bogner
<br />� 11. FATHER'S•NAME (First, Middte, Last, SuHbc) 12. MOTHER'S-NAME (Flret, Mlddle, Malden Sumame)
<br />� Dale Blaine Dickey Marie Thayer
<br />Q- 13. EVER IN U.S. ARMED FORCES4 GWe datea of servtee H Yae. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
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<br />$ �res, No, or unk.) No Kenneth Bagner Husband
<br />a 75. METHOD OF DISPOSRION 16a. EMBALMERSIGNATURE 18b. UCENSE NO. 76c. DATE (Mo., Day, Yr.)
<br />F (� Burial ❑ Donatlon
<br />Daniel D Naranjo 1071 November 18, 2009
<br />❑ Crerr�Uon Q EMambment ��. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Sp�Hyj
<br />Dublin Cemetery Primrose Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (SVeet, City or Town, State) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructtons and exam les
<br />18. PART 1. Fnter the chain ot eveMe-�tliseases, InJur�ea, or complimUorredhat dlrecUy caused the deafh. DO NOT eMer temil�ml evenfe such as cardiae arrest, ; APPROXIMATE INTERVAL
<br />reapiraWry artest, or ve�rtrlcuiar flbrillatlon wNhout showing the etlotogy. DO NOT ABBREVUITE. E�rter oNy o�re puse on a Ms. Add addWonal Ortee Ii �reeessary.
<br />IMMEDIATE CAUSE: p or�et M death
<br />u�meowre cnuse �� a) Respiratory Failure E Immeadiate
<br />disea� or contltdon resultlng
<br />� d �' ) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s��am�uY u�s ��amo�, a b) �rdiopulmonary Arrest : Immeadiate
<br />arry, leading ta tire cause Iisted
<br />an Ihre a. DUE TO, OR AS A CONSE�UENCE OF: : o�et W death
<br />Enter the UNDERLYING CAUSE C )
<br />(tlisease ar InJury that Inttla0sd
<br />tne e"e"re `es"m"e m deau'� DUE TO, OR AS A CONSEGUENCE OF: � onset W death
<br />usr d � ;
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-Condittons contributing to the death but not resulUng In the underlying eause gNen in PART I. 18. WAS MEDICAL D(AMINER
<br />OR CORONER CONTACTED?
<br />� � YES ❑ NO
<br />W 0. IF FEMALE: 21a. MANNER OF DEATH 27b. iF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />W
<br />� � Not pre8�eirt wMh�n past year � Naturai � Homldde � DdveAOperator
<br />� � Pre9neirt et tlme M death � Acdde�rt � Pendln8lnveatl8atlan ❑ Passen9er ❑ YES � NO
<br />� � Not pre9�. bue pregnaM wwdn az aays m aeetn � peaeatr�an 21 d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� Suldae � Comtl not be detemWred TO COMPLETE CAUSE OF DEATH?
<br />� Nat preB�. but preg�ant 49 deys to 1 Yeer betore death � Other (8Pec�tY)
<br />� ❑ Unimown If pregnairt withln the past year
<br />❑ YES ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22e. PLACE OF INJURY•At home, tarm, street, faetory, office bullding, eonstruetion aite, ete. (Speeify)
<br />E
<br />s
<br />.� 22d. INJURY AT WORK4 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />�' ❑ YES ❑ NO
<br />?2(. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYfTOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIONED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />a� ,� �� December 18, 2009 06:00 AM
<br />��� 236. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH �� k y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$„ o E��� November 14, 2009 06:00 AM
<br />. To the best of my Immviedge, death occurted ffi the tlme. dete end plece $�.5 �
<br />end due to the muse a steted. SI naWre and Tttle � r � 24e- On the bae18 of examinatlon end/or InvesUgatlon, In my opinlon death oecurtetl at
<br />� a ( 1 ( 8 l o � p the dme. date and P�aee aed due to tbe puaels) stated. (Signarire and Title)
<br />~$ '" g s Jon Hendricks, Hall Deputy County Attomey
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED7
<br />❑ YES ❑ NO ❑ PROBABLY � UNKNOWN � YES � NO NotAppllwble H28a Is NO ❑ YES ❑ NO
<br />27. E, ITLE AND ADDRESS OF C T FIER PH SIC IC IST T, RON 'S PHYSIC R COU A O EY) (Type or PriM)
<br />Jon Hendricks, Halt Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Isiand, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNA7URE �♦ � 28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.�
<br />December 21, 2009
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