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STATE OF NEBRASKA R. 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 9/26/2017 LINCOLN, NEBRASKA STANLEY S. OPER 2017075 ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Leland Ray Nehls CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Kaamet, Neg,asha w 0. U F U. CL W U E 0 0 7. SOCIAL SECURITY NUMBER 506 -50 -7975 8b, FACILITY - NAME (If not Institution, give street and number) 822`W. 7th St. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a, RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 822 W. 7th St. 10a. MARITAL STATUSAT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes; No, or Unk.) No 15. METH00 OF D.1 ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal >❑ t,3ttler (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island; Nebraska Enter the UNDERLYING CAUSE (disease 01 Mjury that inhi0ad:: the eY@rna rasulting� m death) 20.IF'FEMALE; ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Net pregnant, but pregnant within 42 days of death ❑ Not Pre8na1tt,:but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) tb 22d. INJURY ATWORK? ❑ YES 0 NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed OF INJURY 23a. DATE OF DEATH (Mo., Day, Yr.) September 18, 2017 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH September 18, 2017 06:15 AM O 3d. To the best of my knowledge, death occurred at the time, date and place s C and due to the causes) stated. (Signature and Title) o : S a fa; G revbi ll;:; M D 25. DIP TOBAOGO USE CONTRIBUTE TO THE DEATH? YES ❑ NO ❑ PROBABLY ❑ UNKNOWN REGISTRAR'S SI 5a. AGE Last Birthday 15b. UNDER 1 YEAR (Yrs.) MOS. DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ © DOA OTHER ❑ Nursing Home /LTC Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9. CITY OR TOWN Islnd 9f. ZIP CODE 68801 3. DATE OF DEATH (Mo., Day, Yr.) September 18, 2017 6. DATE OF BIRTH (Mo., Day November 1, 1941 Yr.) 9g.INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name:. Virginia May Murphy 11. FATHER'S -NAME (First, Middle, Last, Suffix) Henry Nehls 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Pearl Warford 14a. INFORMANT- NAME Virginia Nehls 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska CAUSE OF DEATH (See instructions: and examples) 4e. PART I. Enter the. la of events- .diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or.eMnular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a Me.:Add addtonal lines d necessar. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Vascular Dementia disease or condition resulting APPROXIMATE to .death Years in death) Seyuentiallylist condmons if any, Ihsding 10 the gauss tisted on line a DUE TO, OR AS A CONSEQUENCE OF: b)Cerebrovascular Disease onset to death Years DUE TO, OR AS A CONSEQUENCE OF: c) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART 1I. OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Chronic Obstructive Pulmonary Disease, Seizure Disorder 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide © Could not be deterromed 16b €'LICENSE NO. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c.'.PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN >OR TISSUE DONATION BEN CONSIDERED? ❑ YES NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) September 20, 2017 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? YES ®O 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE :OF DEATH? ❑ YES ❑ NO 17b. Zip °Code 68801 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED CITY /TOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCD 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 causetsl stated. (Signature and Tide) 26b. WAS CONSENT GRANTD? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print 1285 Sara Graybill, MD,2116 W Faidley #400, Box 9802, Grandlsland, Nebraska, 68803 G NATURE 16- C '‘. 28b. DATE FILED BY REGISTRAR IMO Day, Yr.) September 21, 2017