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N~r~:n~s .~E6 5901
IIII~INIGV~IVI~IIIIIV
NUM ~d~~ur~~~~ /f'd/
RD. COMP ~ ~ J''Ox
COMPARE ~ ~
CADAS -' AO ~
ADAMS COUNTY, NE
FILED
INST. NO.~` ~~~ ~ $
Date /('7,07 Tim ~~ 9 -.tl.
TER OF DEEDS
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Y. f:Y STATE OF NEBRASKA~(.:.•, '.::. :.. ~i~.~~i5 ~v41 1 _.
,Ijg{:' a , ' • • WHEN THIS COPY CARRIES THE RAISED SEAL' OF THE NEBRASKA HEALTH AND HUMAN SERVICES'.
(z~yj''• ? ': " '.:: 'SYSTEM,.IT CERTIFIES-THE $ELOW TO ~BEA,TRUE COPY OF_ THE ORIGINAL RECORD ONfILE WITH` - ~ ~ , • ~' ! -
•~ cJ„~':_ , _ •,.- " ~ -THE NEBRASKA!HEALTH AND'RUMAN SERVICES.SYSTEM,: VITAL STATISTICS SECTION;. WHICH IS,':' - ~ - •~ _,'."
t : M THE LEGAL DEPOSITORY FOR VITAL. RECORDS.
6 '
I ck~: _ i t . ;DATE OF fSSUANCE ~- r - i', F ~+r tr'ul „' '
i i C7~,+. .. ; ...~L ~ ~ .. .. - .r>,..n y Td 1111 It=_u S:~CD _ R-~ . , . r • - .._ i . .. .
.... t . _ , •,'.~GP ~ 2,- ZOO! ._. .. ^... -.. ' ASSI$TAN-T-~AIE~EG/S ~AR:x ,) , ... .
..
t~q,. _ ;LINCOLN, NEBRASKA ? HEALEHANIkHUNTANBERVICES{~r
rr1,b. ;, ;~.. :t , rfJ ;ti [Ill, Y .,
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~~~~' ~ ' 'r ~ 'STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMANSERVI£~$YFiNANC~kND`SOPPr c} .~ r ,, v _ .
< .. ?; ,:
- - ` ' CERTIFICATE•OF DEATH , .. ~ , ~ :',' '
° , .... .....1. .
~ •Ii DECEDENT'S-NAME..,(Firal,.., '~• ~., 'Middle, •, ;,Last , ,SUlfix)., '" 2. SEXY.-'~' ~3. DATE OF DEATH HMO.; Day YC)•~•-;
" Alan?,"' G.~: ~ ': Boesch ":- •Male Se fember:'2';:.2007'
•4: CITY AND STATE OR TERRITORY,?OR FOREIGN COUNTRY OF BIRTH 6e'. AOE-Leal Blrlhdey 6b. UNDER NEAR Sc: UNDER70AY~ 6. DATE OF BIRTH'(MO., Day, Yr.):"
' • ' ~ '-~ "' ~ - (Vre.)'" MOS. ' DAYS NOURS ~ ~MINS. ' ' ` '
'
E
K '!, Norfolk,; Nebraska,, 53' 1954:
January 23,
•7. SOCIAL SECURITY NUMBER .`_. '.. "-- ~ 9a. PLACE OF DEATH '. •
" :506=70=I940 ' HOSPITAL: ^ Inpallent 4]}ffB ^ Nursing Home/LTF OHOSpice Facllily '
"~ fib. FACILITY-NAME .(II not :inslilullon, give street and number) - ^.ER/Oulpallenl ~gl Decetlem's Home
'~-•-~=5085"Wes t~Cotttinwliod,.Cove ...,. « ' "
.. - - •a ---•, t.-- _.;.,._- :.
-- .~,_,. '^'C04 ... ~ ,.O Other (Spedly)
'fie CITY OR TOWN OF DEATH;(Indudd Zip Code) - - ed. COUNTY OF DEATH'
,
..... ... ; ...... r .
rHastings`'•68901~`~'';_ =
~.
Adams
t9a. RESIDENCE-STATE •~: -. ~ ~~- a.. 9b.000NiY - 9c. CITY OR TOWN .-, '
._:.. N ,, .. Adams.. Hastin s
y :90. STREETAND NUMBER- 5 ~ .. ,- 9e. APT, NO"
~ 91. ZIPCOOE ',9g.INSIDE CITY LIMITS
• • SUSS'.West CO ttORWOOd COVe '~ ~~ ~ ~ ~ ~
I ~~~~ •~ ~ 68901-- ~ ~•- ^ YES .'~Xl NO
1 f 10a. MARITAL STATUS AT TIME OF DEATH ~I' Married -^ Never Married ~ 10b. NAME OF SPOUSE (First, Middle, Lasl, Sullix) II wile, give maiden name. - "
'
--O Married but separated O Widowed ^ Divorced, O Unknown ~ , -
~ •Z nn M': 'Brockhaus - ' - -
. ~ y
x
Midtlle ~ " Lasl,; ' Suffix) ' 12 MOTHER'S NAME (Firs) - .Mldtlle .. Meldan Surname)
~~ ~ 11 FATHER'S-NAME (First„
I~~ .:Harry. ":' •: '• Boesch a Dolores- ~ "':`Kraus'
'
' 13. EVER IN U.S. ARMED FORCES? Give tleles of eervlce ll yes. 14a INFORMANT NAME 14h. RELATIONSHIP TO DECEDENT
'(Yes, no, or unk.)'•tNO '. ~ LyRII each ... W~ife~~:.' .
' ~: ~ t ? 15. METHOD OF DISPOSITION, • '
> Burial ~ ~ = OOonallon ; '~ 16e,E MER- ATU '" ~ ~
~ ~ t6b. LICENSE NO. -
1189 " 16c. DATE (MO.t Day, Yc)
Se tember 7 200.7
s;in.,
i
' ~ ^Cremallon ~OEnlombment ~ 18tl: EMETERY, CRE ATORY-0R OTHER LOCATION - ~ CfTYITOWN ,.. ~ ESTATE ~.
__. ' i .^Removal ~ ^Other (Specily) - '
' •~. ~ ,- -~. .- St...Francis,Cemetery. Humphrey Nebraska
' :' ~-.17e.,FUNERALHOMENAME ANDMAILINGADDRESS.(Slreel, CilycrTown, Stale)" Or m VE'.RUe, ~ 176. Zip Code "
' ~..
- . - ~ -utter-Volland'Funeral' Home" Hastin s Nebraska` '' 168901'°
_. 1. ~ a„~ ' ?'. .. i ' AUS O ' ,'~ x','S e•,':~SEif'Ps}I' 6 .. '--.. .~ 0.. n
r 'tfi. PARTLEnler the cha'n of events--diseesea, Inlurles, or compllcallhns--0hat directly caused the tlealh: DO NOT enter larminal events such as cartllec anesl, ',APPROXIMATE INTERVAL
° I
Y resDirelory arrest; or ventricularlibrilalion without showing the ellology.00 NOT ABBREVIATE. Enter only one cause on aline.Add addillonal lines it necessary. I -
- %' - '- ° - "' - ~ • • Ih1tAEOlATE CAUSE:. - - _ _: . ~ - ~ - 1 onset to death '
:. ~.. .
^ ., _ _ - d fi ,.' 1 "IMMEDIATE CAUSE IFlneI ~ ~ . (a) ~ ~ -- - ... '„
^ ~ p.. }itllaease orwdditlan resulting `. DUE TO, OR AS ACONSEOUENCE OF.' ~ ~~ ~ I ^onsel to tlealh - -
1m' ` In tlealh) _ . ', > . r - .. I ~ '
?Sequentially lief conditlona, ilf ro) _' ~ I
... ~ ~ any, leading to the cause listed I onset to death ~~ ~~
_ DUE T0, OR AS A CONSEQUENCE OF: '
.:...1..' .. '
.. .' `.P i. "on line a.~. - ..-. .., ... .. I
'r -' ~-'~ - ~EnItt IMUNOERLYING CAUSE t' i ` ~ ~- I - "'
~~ -- • =(diseasa of ln)ury lhallnlliatetl t (c) -
„,_~ Neevemsresulling In deem)- - DUE TO, OR ASA CONSEQUENCE OF: ~ i. onset to death "
- ..
I' ,
f .
• '' ! '1 1fi. PART IL OTHER SIGNIFICANT CONDITIONS-COntlllions comrihuting to the death but not resulting in the underlying cause given In PART I. ~ f A. WAS MEDICAL E%AMINER .~ ' ?
-~" ~ -- •'- ~ .. ~ ° .. OR CORONER COr•I,TACTED2 '
f -. ~ OYES , NO
" °. -. '~~ '20: IF FEMALE:' ~ - 21 e.MANNER OF DEATH ', 21 b. IF TRANSPORTATION INJURY 21c WAS AN AIJFOPSY PERFORMED?
°... ' , ; ' LL ~ eluraY O Homlcitle+ ^ DrWer/Operator -. - "
' ~ -ONot pregnenl wlihln Dasl Year ~ .~ .. ,
"' ~11 ~ - ~ - ~ ~ - '~ OPessenger ~ ' ' , O YES- ~NO ~ ~ ,
• - e "^ Pregnant el Ilme of death - , ' '^ Accitlenl0 Pending Invesllgation
' r~• ~ O Npt pregnenl; but pregnant wilhln 42 days of tlealh ~ ~ 21tl. WERE AUTOPSY FINDINGS AVAILABLE TO:
YYYY ^SUldtle OCould not be delerminetl
- . I'q• ~ ~ ^ Other (Speciy)
'^q ^NOlpmgnenl,bulpregnan143 day91otyeer bbloredealh - ....' COMPLETE CAUSEOf DEATH?. ,
p~ ' O Unknown II pregnant wllfiln the past year ~ "" ~ ~ ' ' • ~ O YES ' ~NO
' ' "' " ;'7°~j~ 22e. DATE OF INJURY (MO., Day, Yr.)' 22h. TIME OF INJURY ' 22c. PLACE OF INJURY-AI home, larm, slraet, laclory, office building, conslructian site, eta (Specify)
' - ~ ~ '~"'- 1 ~' K7 22e DESCRIBE HOW INJURY OCCURRED. ~ ,
° ~ ~ r 22d INJURY AT WOR _ "~ ~ ~~ ~ ' ~ m ~ ~ - -
v
..,.
' " ~ '221.LOCATION OFINJURY-STREETB NUMBER, APT.NO. .. :. CITY/lOWN~ STATE ZIP CODE,
'~ '-: ~ ..
- ~ ~ Sae DACE OF DEATH (MO ; Day, Yr) .. z ~ 24e. DATE SIGNED (MO.0ay Yc) 24b.TIME OF DEATH
( :. a4" ., a? p ember_2 2007. " .. aU¢ m
U
::'. '"- 3g~ m>',~ 23b DAiE SIGNED'(Mo Day Vr.)f" 23c.TIMEOFDEATH. ~ &ik 2dc.PRONOUNCEDDEAD'(MO., Day,Yr.)~ 24d. TIMEPRONOUNCEDDEAD '
E°z ~ .~ ~/_"Zac ~-~ ~ - -7:50' m Ep<~ m.
~~, .. ~ iii'
' '"' ~ ~~ ° ~' 23 .TO the best of my knowledge, tlealh occunetl et the Ilme, dale antl place - ' ~ w ~ ~ 24e. On the basis of examination and/or invesligalion, in my opinion tlealh occurred el
• B. ~ '. end due to the cause(s) slaled.• (Slgnalure antl TI e) • g ¢ u Iha Ilma, tlale and place end tlue to the cause(s) sleled. (Signature end Tllle) ~.;' ' ',
r- a /vyr ~s~ ~-,n ~ o,.
25 DIDTOBACCOUSECONTRIBUTE TOTMEDEATH7 r ~ 26a.HAS ORGANORTISSUEDONATION BEENCONSIOEREDT 26b. WAS CONSENTGRANTED7 •-'~ ~~
a ~ - ~ ~ _
?e .": ~,"„ ' ^VES •'•' NO OPRDBABLY. ^tUNKNOWNI. OYES NO ~ Nol Applleeble il26a is NO'OYES" O-~
_. •
' "- ~ '( ~ 27.NAME,TITLE ANDADDRESS OF CERTIFIER IPHYSICIAN,CORONER'S PHYSICIAN OR COUN ATTORNEY)IType or Prinl)~ .- ~' '°. -'~ '
..- L
,:£. :'Michael"G:^Skoch; M.D.', 223 East 14th-Street,-Suite 100, Hastings; Nebraska, 68901
2Ba.REGISTRAR'S SIGNATURE ~: ...~ ^' ' 26b. DATE FILED BY REGISTRAR (MO.. Oey, YrJ
. ,
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