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To be completed /verified by: FUNERAL DIRECTOR ( 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Robert Jacob Lessig Male i3aDA'[EOF DEATH '(.1111o., Day, Yr.) ' •NloVenlber 23, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 87 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) June 18, 1928 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -32 -8141 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER. ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center - 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 1312 N. Elm St. 19e. APT. NO. 9f. ZIP CODE 68801 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 Sherril Lee Owings 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Jacob Lessig 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Amanda Kruse 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 10/17/1950- 09/19/1952 14a. INFORMANT -NAME Sherri) Lee Lessig 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) November 28, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 1 To be completed by: CERTIFIER I I 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 Days 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) Pneumonia disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Sequentially list conditions, if b) I any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Enter the UNDERLYING CAUSE C) I (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: t onset to death LAST d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the' -- " but not resulting in the underlying cause given in PART I. Acute Renal Failure, Dementia, Urinary Retention, Atrial Fibrillation , Diabetes Mellitus, Hyperlipidemia, Hypothyroidism 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES IE 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 ❑ Suicide ❑ 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 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 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 a cc a W n u 23a. DATE OF DEATH (Mo., Day, Yr.) ovember 23, 2015 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) November 25, 2015 23c. TIME OF DEATH I 02:10 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD $ 0 u O 23d. To the best of my knowledge, death occurred at the time, date and place o and due to the cause(s) stated. (Signature and Title) Jay C. Anderson, MD 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? 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 Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 r 28a. REGISTRAR'S SIGNATURE A_ /� p& _ {'O -�V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I November 25, 2015 DATE OF ISSUANCE 11/30/2015 LINCOLN, NEBRASKA STATE STATE OF NEBRASKA 20 1602077 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„,REGOROS STANLEY Cb31 ,ASSITANT STATE REGISTRrARJ DEPARTMENT OF HEALTH A,N,D / HUMANS l l- CE�_`y `° OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S 15 06827 CERTIFICATE OF DEATH