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1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jacquelyn Ann Legg 2. SEX Female 3. DATE OF DEATH (Mo.,Day,Mr.) May 27, 2016 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loup City, Nebraska 5a. AGE -Last Birthday (Yrs.) 57 6h. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 18, 1953 MOS. DAYS HOURS MINS. 7. SOCIAL. SECURITY NUMBER 506 -72 -8206 8a. PLACE OF DEATH HOSPITAL; ® Inpatient OTHER: ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/outpatient ❑ Decedent's Home 0 DOA ❑oeher(speeiry) 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8c. CITY OR TOWN OF DEATH (include Zip Code) Grand Island 68803 Bd. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Doniphan 9d. STREET AND NUMBER 8637 S. Locust St. 9e. APT. NO. 9f. ZJP CODE 68832 9g. INSIDE CITY LIMITS ® Yea ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Melvin G Legg 11. FATHER'S -NAME (First, Middle, Last, Suffix) Leo Kraiewski 12. MOTHER'S -NAME (First. Middle Maiden Sumame) Marie Wroblewski 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT - NAME, Melvin G Legg 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ®Ronal ❑Denetign ❑Cremation ❑Entombment ❑Removal ❑Olhar(steeity) / 18a. EM LMER- SIGNATU ll11 J ) 16b. LICENSE NO. / 9 7 CITY/TOWN Doniphan 18c. DATE (Mo., Day, Yr.) June 1, 2010 STATE Nebraska j 18d. EMETERY, CREMATORY OR OTHER LOCATION Cedarview Cemetery 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART L 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 respiratory arrest. or vermicular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. I Add additional lines 8 necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final - , _ _ _ _ <..? /Q /+ l�,.f %L-`� • / - �� In death) / r S " vt.. 7 ra. i'^ ' In ea dise or condition resulting a) d �� /� /C � DUE TO, OR AS A CONSEQUENCE OF: : onset to death t Sequentially list conditions, e � / / ©© w�/ •-" any, leading to the cause listed b) �.- e'7a1Y /, „lJ/L.e.r a �(C/1.. i on Hne 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 f d) 18. PART 6. OTHER SIGNIFICANT CONDrONS- Conditions contributing to the death but not resulting In the undedying cause given In PART L / h ' /r s' 7 , 1) / 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ❑ NO x 2Q. IF FEMALE: 46 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 ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 210. WAS AN AUTOP PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSF„OF DEATH? ❑ YES ( l0 ?2a. DATE OF INJURY Mo., Day. Yr.) 22b. TIME OF INJURY 1 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) M 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE a w I F E - u a .0 a p 23a. DATE OF DEATH (Mo., Day, Yr.) May 27, 2010 Z >. a a z > 0 a E y � z u W z O 2 0 g, 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) June 2, 2010 23c. TIME OF DEATH 0705 am 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the best of my knowie death occurred at the time, date and place and d aus d. (Signature and Title) 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? / ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? il;i YES ❑ NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Jane McDonald M.D., 800 Alpha St., Grand Island, Nebraska 68803 28a. REGISTRAR'S SIGNATURE 461* 4 ()rim 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) JUN 7 2010 U w re 0 z u. LL 8) d O 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 DEPARTMENT Of HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL OCCIRDS. _ DATE OF ISSUANCE JUN 1 1 2010 LINCOLN, NEBRASKA STATE OF NEBRASKA 201400434 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ArATr rIA ATr Ar l F! A rLI ,. STANLEY S. COOPER' ASSISTANTSTATE REGISTRAR' DEPARTMEN- r HUMAN 'SERVICES