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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW,_ ``1�RUE COPY
<br />-OF AN ORIGINAL RECORD ON FILE WITH THE STATE` '�� HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE L�-
<br />VITAL RECORDS.
<br />DATE OF ISSUANCEa
<br />MAR 141991
<br />STA BY' COOEFi � ECTOR
<br />LINCOLN, NEBRASKA BUREAU 0 T44
<br />#T
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH ^^
<br />I DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Month. Day, Year)
<br />Morris -- Levitan
<br />Male
<br />February 26, 1991
<br />a CITY AND STATE OF BIRTH (ll not inn U.S.A., name country/
<br />(os')
<br />t =
<br />4illi I DA I if, D TE F B RTn l monm, Oay. Year)
<br />-
<br />5b. MOS I DAYS
<br />Jersey City, New Jersey 1
<br />85
<br />5c. HOURS? MINS
<br />May 23, 905
<br />7. SOCIAL SECURITY NUMBER
<br />6a. PLACE OF DEATH
<br />I HOC,rSPITAI'. ❑Inpatient ❑ ER Outpatient ❑DOA
<br />550-03-71]D-
<br />`g OTHER K Nursing Home ❑ Residence ❑ Other (Specify)
<br />8b. FACILITY - Name (If not msNlution, give street and number /
<br />Bc. CITY, TOWN OR LOCATION OF DEATH
<br />So INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />St. Francis Skilled Care
<br />Grand Island, Nebraska
<br />Yesi"Yes orNO)
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9b COUNTY
<br />9c. CITY, TOWN OR LOCATION -
<br />9d. STREET AND.NUMBER .. pncluding Zip Cads) -
<br />"SIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1016 West John
<br />YeS "Yes or Not
<br />t0. RACE - (e.g., White. Black, American Indian,
<br />atc.l lSpecAy/
<br />11. ANCESTRY (e.g.,ltatian, Mexican, German, etc.)
<br />(Specify)
<br />12. MARRIED.NEVER MARRIED,
<br />13. NAME OF SPOUSE (d wile. give maiden name)
<br />White
<br />Russian /Jewish \%
<br />WIDOWED. DIVORCED (Speci")
<br />Married
<br />Lily Giesenhagen
<br />. USUAL OCCUPATION (Give kind of woik done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />1 EDUCATION I-
<br />Of working life. even If retired;
<br />ervice Station /Car Sales
<br />Automotive �O�d,
<br />Elementary or Secondary (0 -12) College 11 -4 or 5.1
<br />8th
<br />FATHER -NAME FIRST MIDDLE LAST 17. MOTHER - MAIDEN NAME FIRST MIDDLE UST
<br />[14.1
<br />Phillip -- Levitan Ida -- Pilli sk
<br />WAS DECEASED EVER IN U.S. ARMED FORCES? 19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.EO. NO.. CITY OR TOWN, STATE. ZIP)
<br />Yea, td, or unlL) (d yes, give war and dates of services(
<br />No Lily Levitan 1016 W. John Grand Island, NE.68801
<br />20a. BURIAL, Cremabon,Removal, -
<br />Doostion :
<br />20b. DATE -
<br />20c. CEMETERY OR CREMATORY - NAME 20d.
<br />LOCATION CITY OR TOWN STATE
<br />_EIV rial
<br />March 1, 1991
<br />Grand Island Cit
<br />Grand Island, Nebraska
<br />LMER.- SIGNATURE 6 LICENSE NO. r'1 L 36
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, 21P(
<br />A fel- Butler- Geddes 1123 W 2nd Grand Island, NE.68801
<br />ME E CAUSE - (ENTER ONLY ONE CAUSE PER LINE FOR (a), (bl, AND (c(( I Interval between onset and death
<br />rPA
<br />UE TO A CONSEOUE Interval between onset and death ile
<br />IbI
<br />UE TO.OR AS A CONSEQUENCE OF: - - .. - - I b"Kvat bslween mmaet and death
<br />I
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing b death but not related
<br />PART
<br />PART III IF FEMALE, WAS THERE A jii
<br />. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />f _
<br />PR.EGN IN THE PAST 3 MONTHS?
<br />`(Sped" sa or NO)
<br />EXAMINER OR CORONER?
<br />/ANCY
<br />LO Yes ❑ No ❑
<br />O •
<br />(SPOOdY Yes or No)
<br />25a. ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />26b. DATE OF INJURY (MO.,Day Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCC RRED
<br />OR PENDING INVESTIGATION (SpscYy)
<br />26e. INJURY AT WORK
<br />2611. PUCE OF INJURY - At home, Ism. street, factory, 28g.
<br />LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE
<br />(Specify Yes or No)
<br />office building, ow. (Specify)
<br />27a.1DATE OF DEATH (Ago-, Day Yf.) _ ^^� -. -
<br />28a. DATE SIGNED (Mo.. Day. Yr)
<br />28b. TIME OF DEATH
<br />February 26, 1991
<br />a
<br />'
<br />aSy=
<br />27b. DATE SIGNED (Mo., Day. Yr.) ,-
<br />27c. TIME OF DEATH -
<br />26c. PRONOUNCED DEAD (Mo., Day. Yr.)
<br />26d. PRONOUNCED DEAD (Hmo
<br />February 27, 1991
<br />1:37 P.M.
<br />'
<br />F
<br />f�!`
<br />3 b
<br />27d. To the beat of my ; death erred at the time date and place and due to the
<br />eauatfs) stated'
<br />28e. On the basis of examination ardror investigation, in my opmon death oxurred at
<br />LXSc b
<br />the time, date and pWce and due to the causelsl stated.
<br />nature and . Idle ► •. ....
<br />'
<br />(Signature and Title)
<br />29a 0 ID TOBACCO USE CONTRIB E THE WTHV
<br />HAS ORGAN OR TISSUE-DONATION BEEN CONSIDERED?
<br />30b. WA CONSENT GRANTED?
<br />.1
<br />❑.YES _ xCe NO O UNKNOWN .,
<br />✓` r ' O YES
<br />❑ YES ONO
<br />O 31. NAME AND ADDRESS RTIFIER. (PHY.S CAN, CORONER•SpHYSICAN OR- COUNTY ATTORN ype or Pruil -
<br />tf 1.
<br />John A. Wagoner Jr. M.D t,800, Alpha Grand.js3and, Nebraska 68803 -
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (MO., Day Yr.)
<br />4
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