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STATE OF NEBRASKA
<br />WHE111 THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AIVD,HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA L�PART,N1E11JT��F, yFALTI j AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ViT6kZ�'R�C�'C�i3D5 � '+ p
<br />DATE OF ISSUANCE � � � � � �
<br />�����A� ' ,; 11 f `� .� .
<br />(� ►+p�j STA1�L�' S. CQQt�R _`" . ' � � . _
<br />2 O�� O� V e1 IT � ASSIS�"AIlIT STiATE-�R �I�RAR
<br />05/14/2012 DEPART`MENT f?F:H'�L'I'}f'�fVD: : .'
<br />LINCOLN, NEBRASKA HLEMANSERVKES:
<br />4 . �� f ,: � `c,y t
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES �;"., £�`,�' �1 t V _, 7 2 01692
<br />GERTIFIGATE OF DEATFI � . � r � ; .,,..' :;• <�, - - - - -
<br />1. pECEDEN7°S•NAME (First, Mlddle, Last, SuHix) :, 2. SIX °:�`_ `�: DATE OF.DEATH (Mo., Day, Yr.)
<br />Joseph Francls Lep�nt Male May 9; 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - last Birthday b. UNDER 1 YEAR Sc: 6lNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(ti'�•) MOS. DAYS HOURS NONS.
<br />Anselmo, Nebraska 86 July 25, 1925
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505-30-9601 HosPrra. � inpaaeM OTH � Nursing Home/LTC � Hosplce Facility
<br />Bb: FACILIIY-NAME (N not InsUhrtton, give street and number) ER/O
<br />� ❑ utpaUent ❑ DecedeM's Home
<br />� Grand Island Veterans Home - 0 ooa ❑ ocner rsPec�ry) -
<br />� 8e.',CI'fY OR TOWN OF DEATH (Include Zlp Code) 8d. COUNTY OF DEATH
<br />S Grand Island 68803 Hall
<br />� 8a. RESIDENCESTATE eb. COUNTY 9a CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />� 9d. STREET AND NUMBER e. APT. NO. 8L ZIP CODE 8g. INSIDE CITY LIMRS
<br />�, 2300 W. Capital Ave. 68803 � rES ❑ No
<br />y 10a. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never Nlarried 10b. NAME OF SPOUSE (Firat, Middle, Laet, Suffix) N wite, pive malden name
<br />d
<br />� ❑ Married, but separated ❑ Widowed � DWorced ❑ Unknown Phyllis Leone Parker
<br />� 17. FATHER'3-NAME (Firat, Middle, Last, SuHbc) 12. MOTHER'S-NAME� (Flret, Mlddle, Malden Sumame)
<br />Joseph Francts Lepant Dorothy Cecilla Rlch
<br />°' 73. EVER IN U.S. ARMED FORCES? Glve dabes of aervice H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />g �res, No, or une.� Yes 06/12/1945-01/31/1947 Ph lis Leone Lepant Spouse
<br />,� 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 76c. DATE (MO., Day, Yr.)
<br />F � Burlal ❑ Donatlon
<br />Laurie D. Sheffield 1397 May 12, 2012
<br />❑ Crerr�Uon Q EMombment ��. CEMETERY, CRENUITORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Speeify)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a: FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, C(ty or Town, State) 17b. ZIp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructions and exam les
<br />18. PART I. EMer the chaln o} eva� dl8easea, inJurles, 01 compUCatlonB�thet dlrecUy causetl the tleath. DO NOT e�r temJ�l ermAS auCh as cerdiac arrest, p AppROXIMATE INTERVAL
<br />reaplratory arteat, or veirtriwlar flbripatlon wMhout ehowing the etiology. DO NOT ABBREVIATE EMer onry orre eauae on a tlrte. Atld addkio�l Ilnee If necewry. -
<br />IMMEDIATE CAUSE: ; onset to death
<br />iemu+mwre cnuse (Finai a) AortiC Stenosis ; Years
<br />tlisease or cond(tlon reaui8np
<br />In death) DUE TO, OR AS A CONSEGUENCE OF: ; onset to death
<br />3equeMlal�y tlst conditlone, H b) ;
<br />eny. leading to the cause Ileted
<br />'� ��� e � DUE TO, OR AS A CONSEQUENCE OF: ; o�et to death
<br />�rure uNn�unNO cause °1
<br />(dlaease or MJury that InitlateA
<br />tfie eve� rewltlng In death) DUE TO, OR AS A CONSEQUENCE OF: t orreet to death
<br />LAST d �
<br />78. PART II.OTHER SIGNIFlCANT CONDITIONS-Cond(tiorre contributing to the death but not reaulUng in the urMeriying cause gNen in PART I. 18. WAS MEDICAL EXAMINER
<br />Coronary Artery Disease, B Thallasemia OR CORONER CONTACTED7
<br />� ❑ YES � NO
<br />W 20. I FEMALE: 27a. MANNER OF QEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />�
<br />� � Not pregnaMw(thln paet year � Natural � Homidde Q DrivedOperaWr
<br />� � PreBnant at tivre W death � AcddeM � PendlnB Invesfl9atlon ❑ PeB�°Bar � YES � NO
<br />� � Not pregnanf, but prepna�rt wlthln 47 daye of deafh � Padestrlan 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />' � Not pregna�rt, but prepnart 49 days to 1 year betore deaW ❑$u1Wde � Cauld not 6e detertNnad ❑ � i (5��) TO COMPLETE CAUSE OF DEATH?
<br />� ❑ Unimown H pregna�n w�thhin tire past year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo„ Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, tarm, street, faetory, office butiding, conatruetlon ske, etc. (Specffy)
<br />�
<br />� 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�-
<br />� YES � NO
<br />22G"LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo„ Day, Yr.) 24b. TIME OF DEATH
<br />S � May 9, 2012 ,� � �
<br />� 23b. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH ��' �¢ 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$� o Ma 10, 2012 08:37 AM a
<br />9d. To the best o( my knowiedge, death occurted at the dme, date end place $ K�� 24e. On the 6asls M examinatlon and/or Inveetlpatlon, In rtry oplMOn Geath oewrteA at
<br />��� a�M due to the cauae(e) sfaled. (Si g n a t ure and Tkte) �� p � q�, � a n G p l a c e a n tl tl u a t o t h a c a u a e( e) e t a D e d. ( S i g n a t u re e n tl T i tl e)
<br />~ Gene L. Wyse, DO '' ;'
<br />2S. ID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />� YES ❑ NO ❑ PROBABLY ❑ UNIOVOWN ❑ YES � NO Not AppUcable H 26a Is NO ❑ YES ❑ NO
<br />27. E, TITLE AND ADD F C TIFIER (PHY , HY 1 UUV T, R P O EY) (Type or Prtrrt)
<br />Gene L. Wyse, DO, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �! 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />May 11, 2012
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