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<br /> - WI�N T1�S COPY CARF�3 flf RA13ED 3EAL OF THE NEBRASKA HEALTH ANQ!iSlIY1JM'rS�CES
<br /> SYSTEII�IT CERT�ES Tlf BELOW TO BE A TRUE COPY OF THE OR/O/NAL�-91V�#��#I
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL STAT/87�3��T/QIY,W�N�
<br /> THE LEOAL DEP031TORYFOR VITAL RECORDS =- '- `� - - �� =-
<br /> DATE OF ISSUANCE �� I�
<br /> �-��___� `:_ _
<br /> /�il�-�'��ADP.�4;
<br /> �R 4 1999 ass���srare�c�sr�t;
<br /> UNCOLN,NEBRASKA HEALTH AND HtT�lAN�3y�TEll�
<br /> STATE OF NEBRASKM D6PARTMENf OF E�AI.TH AND HUMAN SER�3C�FI1�fRN�$.AAID SLJ�ORT
<br /> V1TAL STATfSTICS = - -__ - ---
<br /> CERTIFICATE OF DEATH --�_==_`-
<br /> 1.DECEDENT•NAME FIRST MIDDLE ' UST 2.SE)( 3.DATE OF DEATH /A1oMh.Day.YMr/
<br /> Chong Cha Boeka Female February 11, 1999
<br /> �.CITV AND STATE OF BIRTM Ipnaf i�U.S.A.n�rrN Cp�nby/ Sa.AGE-LYt&rlh09y UNOER 1 YEAFi UNDER 1 DAY 8.DATE OF BIRTH /MOnlh.DYy.Yler/
<br /> Pyongyang,Korea n�� 57 se.►eos. i avs x.HouAS� MiNS. May 08, 1941
<br /> 7.SOCIAL SECURTIV NUMBER M.PLACE OF DEATH -
<br /> 452-25-0020 110SPRAL: � Inp�lisM OTMER: � Nuroing Home
<br /> Bb.FACILITV•Nlme /MnofmfMNiOn,piWIhN/1�MnWnb1/� � � ER Oulp9tl9rn � R�adence
<br /> 3019 Brentwood Court ❑ oon � qnerlSpaMyr
<br /> &.CITV.TOWN pR LOCATION Of DEATN !d.INS�DE CITY IIMITS Be.CWNTV OF DEATH -
<br /> Grand Island ,,„� �,�, � Hall
<br /> W.RESIOENCE-STATE 9b.COUNTV Yc.CITV.TOWN OR LOCATION Od.STREET AND NUMBER /I�Ndiip2'p Cadsl 9e.INSiDE CIT'LIMITS
<br /> Nebraska Hall Grand Island 3019 Brentwood Court,68801 ,,„� N,❑
<br /> 10.MCE-N.P.�.�k.Am�ricm Mtli�n. 1�.ANCESTRY Is.q..Ihlm.Mexiean.fiMmm,Mel :.__.:� 12�MAf�iIED ❑WIDOWED 13.NAME OF SPOUSE IM wds.pw m�i?sn nem�l
<br /> ���y� ���n � NEVER dVORCED Gary Boeka
<br /> 1!L�,,,UdSwU�ALrOCCUPATION !('iiWkMddMWltCbiNCYMNgmOlf 1�b.KMlDOFBU&NESSINDUSTRV 15.EDUCATION �Spaiyony � qrW�campNiW�
<br /> 1:00K�xh'nw�Arsnree� Restaurant EM^r`MeryaSsconeuy�°-'21 '. CdNpsn•�o�s�i
<br /> L
<br /> 1E.FATHER-NAME FIRST MIOOLE UST 17.MOTMER FIRST MIDDLE MAIDEN SUfiNAME
<br /> O Chong Sun Chong Yun Sun
<br /> 1&WAS DECEASED EVER IN U.S.ARMED FORCES4 19a.MlfORMANT-NAME
<br /> �VSS.no.a unk.) IN yes.qiw war Ytl Glq d NrvM`M)
<br /> No Gary Boeka
<br /> 19D.INFpFMANT MAILINO ADDRESS ISTREET OR R.F.D.NO..CfTY OR TOWN.STATE.21P�
<br /> 3019 Brentwood Court,Grand Island,Nebraska 68801
<br /> 20. L�SIGN�LIC 0. � � 21a.METMODOFqSPOSITqN 21D.DATE 21c.CEMETERYORCREMATORV�NAME
<br /> /O �a,,,;,, ��,,,, 02/15/1999 Central NE Cremation Service
<br /> a.FUNERAL MOME-NAME 27d.CEMETERV pR CREMATORV IOCAT1pN CITV OR TOWN STATE
<br /> Apfel-Butler-Geddes Funeral Home �c� ❑o� Gibbon,Nebraska
<br /> 22b.FUNERAL HOME ADDRESS (STREET OR H.F.D.NO..CITV OR TOWN.STATE,21P�
<br /> 1123 West Second Grand Is(and,Nebraska,68801-5899
<br /> 23. IMMEdA7E CAUSE (ENTEp ONLV ONE CAUSE PER LINE FOR lal.ID�.AND(cp I Intervai bstvnsn onset an0 aeatn
<br /> PART �
<br /> I �
<br /> (a) 1
<br /> DUE TO.OR AS A CONSEWENCE OF�. � � IMerval Wlw�sn oro�t anA Oe�M
<br /> i
<br /> ICI i
<br /> DVE TO.OR AS A CONSEOUENCE OF� � Irnerval balween onsel antl death
<br /> I
<br /> I
<br /> ��� I
<br /> OTMER SIGNIFICANT CANDITIONS-Conditiau cpWibu6np b Ihs OaM OW rql rNaled PAHT III tF FEMALE.WAS TNERE A 2e AUTOPSV 25.W AS CASE REFERRED TO MEDICAL
<br /> PART PREGNANCY IN THE PAST 3 MONTHS? E%AMINER OR CARONER?
<br /> II
<br /> �Ages 10•Sr) Yea No Yes No Ves No
<br /> Z6a. 26b.DATE OF INJURV (A10..Dey.Yc� 26c.HOUR OF INJURV 28d.DESCRIBE MOW INJURV OCCURRED
<br /> � AcciOent � UnEetermined M
<br /> � Su�c�ee � PenAmg 26e.INJURV AT WOHI( Z&.PUS��RY��,prm.sheet lacloiy 26g.LOCATION $TREET OR R.F.D.NO. CITY OR TOWN - JSTATE
<br /> ❑ ❑ ❑ dR
<br /> HomicWe Investigalia+ Vss No
<br /> 27a.DA7E OF DEATH (MO.Day Yr./ 2Ba.DAiE SIGNED /MO..Day Yr.! 28D.TIME OF DEATH �
<br /> 3 found at
<br /> 3'< Sil� � � • M
<br /> `�'j. 2�C DA7E SIGNED Ab.Day.Yr1 27a TIME OF DEATM �K 2Bc.PRONOUNCED DEAD lMO.Day,YU 28d.PRONOUNCED OEAD lNOU�I
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<br /> ,°.� 270.To iha Dsat d my knowlsOga.Esath acurreE at IM 6ro.daq ard Wce and due b IM 8� 28e.On Me basis d s■minatlon anA�a� � 6m.in my • occurr t
<br /> eauselsl�ered. . � Ihe Gme.Cab an0 pace an0 Eue aussls)steted.
<br /> � na�we antl Titb Wre anA Titb �
<br /> 29.D�D TOBACCO USE CONTRIBUTE TO THE DEATH4 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.D AS CONS GRANTEO?
<br /> � VES � NO � UNKNOWN � YES I VI NO � YES h71 NO
<br /> YL YY
<br /> 31.NAME AND ADORESS OF CEHTIFIER fPHV$ICIAN,COqONER'S PHVSICIAN OR COUNTV ATTORNEVI ITyp p Prinry . �
<br /> 7 n
<br /> 3IIa. 61STRAH .DATE E TRAR /Mn.Day.Yr./
<br /> . �
<br /> FEB 2 41999
<br /> L.D'f" 2,Z .�1/Y� � �s�,�-/�)n.,.� �i�Li.�i��ii'c.�,-,,. �. �_ ,. �'
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