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WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD j_ NLkfflTH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC$ . , THE LEGAL DEPOSITORY FOR VITAL RECORDS." DATE OF ISSUANCE 200103266 AC�f y - APR 10 NMI ASS/ = LINCOLN, NEBRl OF NEBRASKA- DEPARTMENT OF H ND S JiL �[S PPB T VffAL STATISTICS _ 03628 CERTIFICATE OF DEATH 1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX - =-_ F DEATH /Month. Day Ye9rl Male April 2, 2001 James Philip Lee r a. CITY AND STATE OF BIRTH Id not in USA.. name county) 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year) Denver, Colorado (Yrs.) 52 sb rws. Days September 20, 1948 5c. HOURS' MINS. 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH 506-58-7700 HOSPITAL ® Inpatient OTHER [j Nursing Home ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name /M not institution. give steel and number) St. Francis Medical Center ❑ DOA ❑ Other /Specdyl 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island Yee I ❑ I Hall Ho 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Code) 9e INSIDE CITY LIMITS Mbraska Hall Grand Island 4.35 2nd St. 68801 [F] Yes No 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /It wde. give maiden name) etc.) (Specify) White (Specify) American NEVER DIVORCED MARRIED Nancy S h u n kw i l e r I 14a. USUAL OCCUPATION /Give kind of work done during most tab KING OF BUSINESS INDUSTRY 15. EDUCATION ( Speciy only highest grade completedl of working life, even /f retired) Elementary or Secondary 10 12) College I1 -4 or 5•I Janitorial 16. FATHER - NAME FIRST MIDDLE LAST 17. MOT ER FIRST MIDDLE MAIDEN SURNAME Ira Lee 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT -NAME (Yes . no. or unk.) Ill yes. give war and dates of services) Nancy Lee no 19b. INFORMANT MAILING ADDRESS SSTREET OR RP D NO_ CITY OR TOWN, STATE. ZIPI 415 2nd St Grand 20. E8 ICENSE 21 a. METHOD OF DISPOSITION 21b. DATE CEMETERY OR CREMATORY -NAME �21c. Grand Island City IOW d ® Burial ❑ Removal April 5,2001 22 NERAL HOME - NAME 21d. CEMETERY OR CREMATORY LOCATION ITY OR TOWN STATE ❑Cremation ❑°°"aeon Grand Island, Nebraska All Faiths Funeral Home 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP( 2929'S. Locust St. Grand Island, Nebraska 68801 23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (cl) I Interval between onset and death PART I I I (al DUE T0,0 A tONSEQUENCE OF Interval between onset and death I @I .1 DUE TO. OA AS A CONSEQUENCE OF Interval between onset and death I (cl t1 G I OTHER SIGNIFIXNT CO NATIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25, WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS, EXAMINER OR CORONER? II p , (Ages 10 -541 Yes D No R Yes No Yes No 26a 266. DATE OF INJURY (Mo.. Day. Yc) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED 0 Accident F] Undetermined M Suicide r-1 Pending 26e. INJURY AT WORK 26f. PLLAqCE OF INJURY - At homy. )arm. street. factory budding. etc. /SpecnyJ 26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE Homicide Investigation Yes No ❑ ❑ oeice 27a. DATE OF DEATH /Mo.. Day Yr.) 28a. DATE SIGNED (Mo.. Day. Yr.) 28b. TIME OF DEATH April 2, 2001 a> 1"s i in M 27b. GATE SIGNED /MO.. Day? Ycl April 4,2001 27c. TIME OF DEATH 1 1 28c. PRONOUNCED DEAD (Mo. Day. Yr) 28d. PRONOUNCED DEAD (Hourl 17:10 M ¢ r M ° § 27d. To the best of my knowledge. occurred at the time. date and place and due to the 28e. On the basis W examination and'or investigation, in my opinion deem occurred at ° causal slated. ° ' the time, date and place and due to the cause(s) stated. ISi nature and Title) /1110 - nature and Tile ► 29. DID TOBACCO USE CONTRIBUTE TO THE OEAT 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES NO 1:1 UNKNOWN � YES E] NO ❑ YES NO 31, NAME AND ADDRESS OFYYCERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) IType or Print) IIhomas Werner, M.D., 2444 W. Faidley. Ave. , Grand Island, NE 68803 1 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (MO.. Day. Yr.) APR 9 2001 0 - a-`"