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0 R t\ O N J WHEN THIS COPY CARRE S TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA_N_SPRVICES SYSTEM, RCERTIFIES TIE BELOW TO BE A TRUE COPY OF THE ORIGINAL - - _ JMTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 200003318 COQ LINCOLN, DEC RASIG4�� HEALTHAND� STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SViS FBF AND SEIPPORT VITAL STATISTICS - - - - CERTIFICATE OF DEATH 1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX M LeRoy C Peyton Male n n Sa. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY net. E DATE OF BIRTH /Mo Day Year) Sb.MOS l DAYS Sc.HOURS' MINS Burwell, Nebraska T July 20, 1928 7. SOCIAL SECURTIY NUMBER = D HOSPITAL: Inpatient OTHER ❑ Nursing Home ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name /Nrot ristaution, give sheet and num6ar) rn ❑ DOA ❑ Other/specdfr Sc. CITY. TOWN OR LOCATION OF DEATH C Z Be. COUNTY OF DEATH Lincoln M CA tY. RESWENCE -STATE o n cn o 9e INSIDE CITY LIMITS = D Grand Island 3004 W. 17th St. 6880 Yes ® No ❑ 10. RACE - III White. Black. American Iran. 11. ANCESTRY (e.g.. Italian. Mexican, German, etc) 12. � MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /If wile. give maiden name! c D ($peCL.nglish /Danish NEVER DIVORCED M N S tab. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Spectty only highest grade completed) of vro king life. even it relved) Journeyman Electrician Electric Elementary or Secondary l0 -12) College n .4 of 5.1 1 m M m N co G]. 19a. INFORMANT -NAME (Yes. no or unk.) (If yes give war and dates of services) No I Marcella Peyton 19b. INFORMANT MAILING ADDRESS (STREET OR FIT D NO, CITY OR TOWN. STATE. ZIP) 3004 West 17th Street Grand Island, Nebraska 68803 t7 "� , CD Co a Burial ❑Removal Nov. 4, 1999 Cottonwood Ciemeter RAL DIME -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE o N O -*T O 3213 West North Front Street Grand Island, NE 68803 23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR dal. (b). AND (c)) Interval between onset anc dean PART I I(al Intracranial Aneurysm 1 month CJ 1 Z C7 { Z M M n ao O D a) W CD cn CD N W CO co WHEN THIS COPY CARRE S TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA_N_SPRVICES SYSTEM, RCERTIFIES TIE BELOW TO BE A TRUE COPY OF THE ORIGINAL - - _ JMTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 200003318 COQ LINCOLN, DEC RASIG4�� HEALTHAND� STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SViS FBF AND SEIPPORT VITAL STATISTICS - - - - CERTIFICATE OF DEATH 1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Month. Day Year) LeRoy C Peyton Male October 30, 1999 4. CITY AND STATE OF BIRTH /Onot kt USA.. name country/ Sa. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY net. E DATE OF BIRTH /Mo Day Year) Sb.MOS l DAYS Sc.HOURS' MINS Burwell, Nebraska (Yrsl 71 July 20, 1928 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH 508 -30 -3044 HOSPITAL: Inpatient OTHER ❑ Nursing Home ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name /Nrot ristaution, give sheet and num6ar) BryanLGH Medical Center West ❑ DOA ❑ Other/specdfr Sc. CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH Lincoln - - Yes B No ❑ Lancaster I tY. RESWENCE -STATE 91p . COUNTY 9c. CITY. TOWN OR LOCATION , 9d. STREET AND NUMBER /including Zip code' 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 3004 W. 17th St. 6880 Yes ® No ❑ 10. RACE - III White. Black. American Iran. 11. ANCESTRY (e.g.. Italian. Mexican, German, etc) 12. � MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /If wile. give maiden name! Mite ($peCL.nglish /Danish NEVER DIVORCED Marcella Stoural 14a. USUAL OCCUPATION (Give kind of work done during most tab. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Spectty only highest grade completed) of vro king life. even it relved) Journeyman Electrician Electric Elementary or Secondary l0 -12) College n .4 of 5.1 1 16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Lewis Peyton Neola Lenker 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT -NAME (Yes. no or unk.) (If yes give war and dates of services) No I Marcella Peyton 19b. INFORMANT MAILING ADDRESS (STREET OR FIT D NO, CITY OR TOWN. STATE. ZIP) 3004 West 17th Street Grand Island, Nebraska 68803 20.E BALM ER - SIGNATURE 8 ICENSE NO. 21 a. METHOD OF DISPOSITION 21 b. DATE 21c. _ CEMETERY OR CREMATORY NAME a Burial ❑Removal Nov. 4, 1999 Cottonwood Ciemeter RAL DIME -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Klein Funeral Home El Cremation ❑Donaldon ,Burwell Nebraska _ 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP) 3213 West North Front Street Grand Island, NE 68803 23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR dal. (b). AND (c)) Interval between onset anc dean PART I I(al Intracranial Aneurysm 1 month UUE I U, UH AS A CUNSEUUENUE W I Interval between onset and death I (b-, Pneum i is 1 month DUE TO. OR AS A CONSEQUENCE OF Interval between onset a,d death OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART PREGNANCY II III IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS? 2 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER (Ages 10 -54) Yes No Yes No Yes No FX 26a. 26b. DATE OF INJURY /Mo.. Day. Yr.) 26c. HOUR OF INJURY 1 26d. DESCRIBE HOW INJURY OCCURRED Accident Undetermined I M Suicide Pending Homicide Investigation 26e. INJURY AT WORK Yes No ❑ ❑ 261. PLACE OF INJURY - Al homy, term, street. factory o Ice budding. etc. /Specify 269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 27a. DATE OF DEATH (Mo. Day Yr.) 28a. DATE SIGNED /Mo.. Day. Yr.l 28b TIME OF DEATH y October 30, 1999 <= `a�' r M 27b. DATE SIGNED /MO. . Yr) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD (Mo. Day, Yr.) 28d PRONOUNCED DEAD /Hour Novi e 3, 19 2220 M ° a M 27d To the best of my k ge. ea81 etl at a tin1e. dale nd dace and due to Me cause(s) stated. 28e. 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 (Signature and TNe 29. DID TOBACCO USE CONTRIBUT E DEATH? ❑ YES NO ❑ UNKN 30.8 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES NO 30.b WAS CONSENT GRANTED' ❑ YES �._ 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Bob J. Bleicher, M.D. 1500 South 48th St Suite 605 Lincoln, NE 68506 N^ \ lam unr1 1u tor" Wt,r nnn '. tray. yri