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I WHEN THIS COPYCARMES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUM SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECCO THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIW, -- THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE y FEB 17 2000 200002292 ASS/BTi j f7 LINCOLN, NEBRASKA HEALTH AND HU141A11C fi $M STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICESFINA VITAL STATISTICS CERTIFICATE OF DEATH 1--DECEDENT -NAME FIRST MIDDLE LAST i" T Jay Edwin 4. CITY AND STATE Leininger 11 � 2 SEX Male 3. DATE OF DEATH (MOntn Day Yearl February 5, 2000 O=bIHTIHj1fW1v 26a 26b E OF INJURY /MO. Day. 26c HOUR OF INJURY (Ages t0 -54) I— No Yes No Yes No 26d. DESCRIBE HOW INJURY OCCURRED NDER 1 YEAR UNDER t DAV 6. DATE OF BIRTH lMOnlh. Day Year) Laramie 27a. DATE OF DEATH /Mo. Day Yr.) MOS DAYS 5c. HOURS MINS =� 7. SOCIAL SECURTIV NUMBER M i 2gc. PRONOUNCED DEAD IMO Day. YrJ 28d. PRONOUNCED DEAD (HOUrI g February 8, 2000 12:36 PM ¢z z ° 27d. To the best of my knowledge deem occurred rhe time, date and place and due to th ~ cause(s) stated. o - M - o 28e. On the basis of examination 'or Ju ne 7 , 1942 and invesugatlon, in my opinion Peale occurred at the lime, date and place and due to the causefs) stated. PLACE OF DEATH )Si nature and Title) If. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED 30.b WAS CONSENT YES NO UNKNOWN 508 -48 -2495 HOSPITAL ® Inpatient OTHER 0 Nursing Home Bb. FACILITY -Name /lI not rnsfilution, give sheet and number) W. J. Landis M.D. 2444 Faidley, G and Island, NE. 68803 32a. REGISTRAR ER Outpatient O Residence St. Francis Medical Center 32b. DATE FILED BY REGISTRAR /Mo. Day Yr./ DOA El 8c. CITY. TOWN OR LOCATK)N OF DEATH Omer /Specrtvt - Grand I 1 90.. INSIDE CrtY LIMITS Se. COUNTY OF DEATH s and Yes ® No ❑ Hall V6w ENCE - STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9tl. STREET AND NUMBER !Including Lp Code) 9e INSIDE CITY LIMIT S braska Hall Doniphan 102 South St., 68832 - )e.g., White. Black American Indian. 11. ANCESTRY le g. Italian. Mexican. German, etc) 12. © MARRIED Yes Mi No El pecdy) ET 13 NAME OF SPOUSE 111-11 gwe maiden name) White (Specify) NEVER DIVORCED Glenda J. Powers L OCCUPATION lGrve kind of work done durin most MARRI rking /ile, even 4renred) g 14b KIND OF BUSINESS INDUSTRY 15. E DUCATION (Specity only mghest grade completed 1 Owner /Operator Carpentry ElerunryorSecondary 1012) College 11.4 R -NAME FIRST MIDDLE LAST 17 MOTHER 1 FIRST MIDDLE MAIDEN SURNAME Gerald Leininger Marie Brown DECEASED EVER IN U S ARMED FORCES' 19a. INFORMANT - NAME r,r unk.) If es. ve war antl oalev of serdcesl - - - -� -- ! Yes: 2�2 -966 2 -4 -_1968 Glenda J. Leininger 79b INFORMANT MAILING ADDRESS ISTREET OR R F.D NO., CITY OR TOWN. STATE. ZIP) 102 South St., P.O. Box 8, Doniphan, NE 68832 20. EMBALMER - SIGNATURE 8 LICENSE NO 21 a:METI OD DF DI SPOSITION 2tb. DATE // //) � J 21 c. CEMETERY OR CRE® nal [] Remn�al Feb. 2000 Cedar View Cemetery 22a FUNERAL HOME NAME 21d CEMETERY OR CREMATORY LOCATION CITV OR TOWN STATE Apfel- Butler - Geddes 10mation ❑ Donakon Doniphan, Nebraska 22b FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO_ CITY OR TOWN. STATE, ZIP) 1123 West Second, rand Island, NE. 68801 21 IMMEDIATE CAU E (ENTER ONLY ONE CAUSE PER LI OR (a). (b) AND (q) 1 PART Interval between onset an � DUE TO, OR AS A CONSE U CE , \ lerval betwonset and d tl� DUE TO. OR AS A CONSEO ENCE OF •�....., -_... -..'- Interval between orset , nFaln. J PART OTHER SIGNIFICANT CO DITIONS - Cmdrtions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 11 � WAS CASE REFERRED MEDICAL PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER R 26a 26b E OF INJURY /MO. Day. 26c HOUR OF INJURY (Ages t0 -54) I— No Yes No Yes No 26d. DESCRIBE HOW INJURY OCCURRED Accident � Undelerm�ned I�1 L I SwIode n P -rr,e4 26e INJURY AT WORK 26f. PLACE %INJURY - Al home. farm, Homicide Invesl,gaoon Vas ❑ No F] otlice bwIding. etc /SFie,iry/ M street. factory 26g. LOCATION STREET OR R.F D. NO CITY OR TOWN —STATE- 27a. DATE OF DEATH /Mo. Day Yr.) 28a. DATE SIGNED /Mo.. Day Yil 28b TIME OF DEATH = February 5, 2000 =� ��, g > 27b DATE SIGNED IMO.. Oa Yr Y I 27c TIME OF DEATH M i 2gc. PRONOUNCED DEAD IMO Day. YrJ 28d. PRONOUNCED DEAD (HOUrI g February 8, 2000 12:36 PM ¢z z ° 27d. To the best of my knowledge deem occurred rhe time, date and place and due to th ~ cause(s) stated. o - M - o 28e. On the basis of examination 'or )S, nature and invesugatlon, in my opinion Peale occurred at the lime, date and place and due to the causefs) stated. and Title(► C�-i`J DID OBACCO USE CONTRIBUTE TO THE DEATH? 30.a )Si nature and Title) If. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED 30.b WAS CONSENT YES NO UNKNOWN G RANTED YES. NO YES NO 31. ME AND ATMHLSb OF CERTIFIER (PHYSICIAN. CORONERS PHYSICWN OR COUNTY ATTORNEYI rType or Prinp W. J. Landis M.D. 2444 Faidley, G and Island, NE. 68803 32a. REGISTRAR (IMP 32b. DATE FILED BY REGISTRAR /Mo. Day Yr./ _ FEB 11 2000 T,