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_ 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Constance Lucille Legler 2. SEX ' Female'- , .3: BATE OF DEATI. (Mo., Day, Yr.) , January 4, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Worthington, Minnesota 5a. AGE - Last Birthday (Yrs.) 75 5b. UNDER 1 YEAR 5c. UNDER 1 DAY. 6. DATE OF BIRTH (Mo., Day, Yr.) August 26, 1937 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 476-38 -0326 8b. FACILITY -NAME (If not Institution, give street and number) 1521 Mansfield Road 8a. PLACE OF DEATH H OSPI TAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1521 Mansfield Road e. APT. NO. C 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Marlin Legler 11. FATHER'S -NAME (First, Middle, Last, Suffix) Russell Wayne Olson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lucille Edna Manuel 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Marlin Legler 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) January 4, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Immediate respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Heart Attack disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Chronic Obstructive Pulmonary Disease any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: ® Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suldde ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c, WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE LL i 23a. DATE OF DEATH (Mo., Day, Yr.) g t I E ., ,. 1 ° < = O w 2 w p 8 8 24a. DATE SIGNED (Mo., Day, Yr.) January 4, 2013 24b. TIME OF DEATH Approx. 12:01 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH I 24c. PRONOUNCED DEAD (Mo., Day, Yr.) January 4, 2013 24d. TIME PRONOUNCED DEAD 08:15 AM O 9d. To the best of my knowledge, death occurred at the time, date and place $ . and due to the cause(s) stated. (Signature and Title) 24e. On the basis of examination and /or Investig tion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Dave Medlin, Hall Deputy County Attomey 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Dave Medlin, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a . REGISTRAR'S SIGNATURE /1+ 4 I� _r, 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I January 8, 2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPAR.TMFNT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALRECOyD : ; DATE OF ISSUANCE 01/10/2013 LINCOLN, NEBRASKA STANLEY S COOPER ASSISTANT STATE REGISTRAR DEPARTMENT Of- HEALTH AND,;, HUMANISER.C{E,S STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES.-. 13 00059 CERTIFICATE OF DEATH 201300569