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STATE OF NEBRASKA
<br />WHEN ` THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE ;A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11/15/2016
<br />LINCOLN, NEBRASKA
<br />c hE ICF ST
<br />R -Sf _h,�, - ^ .,,, ATC I9h. COUNTY
<br />Nebraska
<br />• 9d. STREET ANDNUMBER
<br />4071 Timberline Street
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, bUt separated ; g Widowed ❑ Divorced ❑ Unknown
<br />Hall
<br />28a. REGISTRAR'S SIGNATURE
<br />2O17006Oj
<br />( Sc. CITY OR TOWN
<br />Grand Island
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, Mri 729 North Custer Avenue, Grand Islam:, Nebraska, 6880'3
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
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<br />STANLEY S.1OOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Lelia Christine Luhn
<br />4. C,ITY.AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hooper, Colorado
<br />7. SOCIAL SECURITY NUMBER
<br />508 -40 -2228
<br />8b. FACILITY -NAME (If Mot InBtitution, give street and number)
<br />Good Samaritan Society -Crane Meadows
<br />5a.
<br />AGE - Last Birthday
<br />(Yrs.)
<br />93
<br />513. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island: 68803
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 1, 2016
<br />November 24, 1922
<br />6. DATE OF BIRTH (MO., 'Day, fir:)'
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />® Other (SpecifyWSSISTED I.
<br />❑ Hospice Facility
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<br />8d. COUNTY OF DEATH
<br />Hall
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<br />• Jerry S Lincoln
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<br />E �13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />I-
<br />m, death) ,.;
<br />Sequentially list conditions, if
<br />any, leading to the pause listed
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Percutaneous Gastric Tube Dependent Due To Chronic Dysphagia And Zenkers
<br />Diverticulum
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<br />a.
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />15. METHOD OF DISPOSITION
<br />® Buda! ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />0 Removal . <❑ Other; (Specify)
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home. 1123 W. 2nd, Grand Island. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />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,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause On a fine, Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Chronic Aspiration
<br />(dlseave ttr inju that mittated
<br />the
<br />e events `es'iau+gm death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST.: ;I :! d) .
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Peg Tube Dependent With Chronic Aspiration. Family And Patent Transferred To Hospice Care
<br />0. IF FEMALE:
<br />❑ Not pregnaritWithin past year
<br />❑ Pregnant at time of death
<br />Not pre bat pregnant within 42 days of death
<br />Nat preg nant, but R egnanf 43 dr
<br />❑ Unknown ys tot yey, before death
<br />if pregnant Withil3the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT:WORK?
<br />❑YES ❑NO
<br />22f. LOCATION OF INJURY- STREET & NUMBER, APT.NO.
<br />CITY /TOWN
<br />STATE
<br />ZIP CODE
<br />a v
<br />, W
<br />23•. DATE OF (DEATH (Mo., Day, Yr.)
<br />m
<br />Noveber 1 2016
<br />23b. DATE StONED (Mo., Day, Yr.)
<br />November 11, 2016
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES gl NO ❑ PROBABLY ❑ UNKNOWN
<br />10b. NAME OF SPOUSE (First, Middle, Last,
<br />Wilford Li/ hn
<br />14a. INFORMANT -NAME
<br />Sherman Luhn
<br />16a. EMBALMER-SIGNATURE
<br />Derek Apfel
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Mt. Pleasant Cemetery
<br />CITY / TOWN
<br />Cairo
<br />STATE
<br />Nebr
<br />22b. TIME OF INJURY
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) sated. (Signature and Title)
<br />Michael A, Donner, MD
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could<nut be determined
<br />23c. TIME OF DEATH
<br />02:00 AM
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />I9e. APT. NO. 19f. ZIP CODE
<br />! 6380::
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Jessie I Ashton
<br />16b. LICENSE NO.
<br />1240
<br />214, IF TRANSPORTATION INJURY
<br />❑ DYrver/Operator
<br />❑ Passenger
<br />Pedestrian
<br />0 Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN: CONSIDERED?
<br />❑ YES EI NO
<br />Suffix) If wife, give maiden name
<br />9g. INSIDE CITY LIMITS
<br />E YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo., Day, Yr.)
<br />November 5, 2016
<br />17b, Zip Code
<br />68801
<br />A PP ROXIMATE:INTERVAL
<br />onset to death'
<br />Immediate
<br />onset to death
<br />Years
<br />onset to death
<br />Years
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 10140.
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES Ejl NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED 0
<br />24e. On the basis of examination and /or investiga ion, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑YES ❑.NO
<br />28b. DATE FILED BY REGISTRAR(Mo„ Pay, Yr.)
<br />November 14, 2016
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