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STATE OF NEBRASKA S i WHEN > THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 RECORDS DATE OF ISSUANCE 7/7/2016 LINCOLN NEBRASKA A mended STAN S. C OPER 201604917 ASSIS ANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Shirley Maureen Leago 4, CITY A D STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Stuart, Nebraska 7. SOCIAL SECURITY NUMBER 505 -50 -2242 6b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE-STATE Nebraska 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 5a, AGE - Last Birthday (Yrs.) 76 9b. COUNTY Hall 5b. UNDER 1 YEAR MOS. 9d. STREET AND NUMBER 2911 West 16th Street DAYS 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 9f. ZIP CODE 68803 3. DATE OF DEATH (Mo., Day, Yr.) June 3, 2016 6. DATE OF BIRTH (Ma, Day, Yr.), November 8, 1939 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ 00A OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9g. INSIDE CITY LIMITS ® YES ❑ NO lob.. NAME OF SPOUSE (First, Last, Suffix) If wife, give maiden n Jasper Benny Leago 11. FATHER'S -NAME (First, Middle, Last, Suffix) Emil Colfack 12. MOTHERS -NAME (First, Middle, Maiden Surname) Erma Arp 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 20. IF FEMALE: 0 Not pregnant within past ❑ 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 22a. DATE OF INJURY (Mo., Day, Yr.) 22d..INJURY ATWORK? YES Q NO 23a. DATE OF DEATH (Mo., Day, Yr.) June 3 2016 23b. DATE SIGNED (Mo., Day, Yr.) June 6,'2016 14a. INFORMANT-NAME Jasper Benny Leago 16a, EMBALMER- SIGNATURE Katie M. Smydra 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suic de ❑ Could not be determined lSb. LICENSE NO. 1454 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) ta. 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, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Adenocarcinoma Of Lung, Metastatic Disease To Brain 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. History Of Osteoporosis, Fractured Right Hip, Osteoarthritis, Hypertension, Hyperlipidernia 21b. IF TRANSPORTATION INJURY ❑. Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (MO., Di y, Yr.) June 9, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Grand Island City Cemetery Grand Island STATE Nebraska 17b. Zip Code 68801 IMMEDIATE CAUSE (Final disease or condition resulting APPROXIMATE INTERVAL onset to death 2 Months in death) Segtpintially list conditions, if any, leading to the. cause listed on li ne., DUE TO, OR AS A CONSEQUENCE OF: b) Past Medical History Tobacco Use Onset to death Years Enter the UNDERLYING CAUSE (disease or injury that initiated Me events resulting m death) LAST DUE TO, OR AS A CONSEQUENCE OF: C) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES 0 N 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/Tf)WN STATE ZIP CODE 23c. TIME OF DEATH 12:50 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jane: A. McDonald, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES P._ NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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(e) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo.,'Day, Yr.); June 6, 2016 Amended 7/7/2016 Item 23c Corrected To A.M.