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STATE OF NEBRASKA niiiMovinciszmi re w U 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 10/31/2017 LINCOLN NEBRASKA Mo., Day,:Yr.) 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Yvonne Jean Leisinger 4, CITY AND STATE OR :TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 506 -28 -9289 Pb. FACILITY -NAME (If not Institution, give street and number) Grand lstand Bickford Cottage L.L.C. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 911 W. 7th St S. MARITAL STATUS AT TIME. OF DEATH ❑ Married ❑ Never Married D. Married, brat separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Joseph Bosler 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 ❑:; RemPYai :❑ Other (Specify) 7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska 6. PART I. Enter the Chain of events- injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, orventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only One cause one line, Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Progressive Dementia, Parkinson's Disease disease or condition resulting in death) Sequentially hot conditions, if : b) any, leading to the' cause Listed on line a. -- Enter the UNDERLYING CAUSE (disease dr it ury ;tkat in ti ted 'the eusnts resuhtttq to dead)) ` ':. DUE TO, OR AS A CONSEQUENCE OF: LAST j d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hypertension, ;Vitamin 912 Deficiency, Depression, Essential Tremor 22a. DATE OF INJURY (Mo., Day, Yr.) d. INJURY AT WORK? D YES 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Katie M. Smvdra. Westlawn Cemetery DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: C) 20. IF FEMALE: t ❑ Not pregnant within past year Pregnant at time of death © Notpregnant, Put pregnant within 42 days of death Not pregnant but pregnant days to 1 year before death C Unknown if pregnant Within the past year 22b. TIME OF INJURY 22e, DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 23a. DATE OF DEATH (Mo., Day, Yr.) m' October 19 2017 LL 14 p:::: ; • re J b O Z u: ¢ 0 9d. To the best of my knowledge, death occurred at the time, date and place Y and due to the cause(s) stated. (Signature and Title) r Jane,A. McDona MD 5a. AGE - Last Birthday (Yrs.) 201707693 CITY /TOWN 23 DATE SIGNED (Mo., Day, Yr.) October 27, 2017 23c. TIME OF DEATH 03:02 PM 87 8a. PLACE OF DEATH HOSPITAL 0 Inpatient �- ❑ ER/Outpatient D DOA 9c. CITY OR TOWN Grand! Island lob. NAME OF SPOUSE (First, Middle, Last, Donald C ' Leisinger 14a. INFORMANT- NAME Kaila Lynne Roeser. 1 12. MOTHER'S -NAME (First, Middle, Marguerite Smith 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN CAUSE OF DEATH (See instruc i ins and examples) 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined b. UNDER 1 YEAR MOS. DAYS APT. NO. 16b. LICENSE NO. 1454 2. SEX Female HOURS Grand Island 21b, IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian 0 Other, (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) Y ' 15 1 1; :U ee 8 rc 2z O O O 2 5. DID TOBACCO U$E CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES] NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 2 NO 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 Sit:MAT(IRE � STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 5c. UNDER 1 DAY MINS. ad. COUNTY OF DEATH Hall 9f. ZIP CODE 68801 4c. PRONOUNCED DEAD (Mo., Day, Yr. 3. DATE OF DEATH (Mo., Day, Yr.) October 19, 2017 6. DATE OF BIRTH (Mo., Day, November 7, 1929 OTHER ❑ Nursing Home /LTC ❑ Decedent's Home Other (Specify)ASSISTED LIMING Suffix) If wife, give maiden name Maiden Surname) ❑ YES ® NO 28b. DATE FILED BY REGISTRAR October 27, 2017 ❑ Hospice Facility 9g. INSIDE CITY LIMITS" ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Daughter 16c. DATE (Mo., Day, Yr.) October 24, 2017 STATE Nebraska 17b,Zip;Code 68801 APPROXIMATE INT ERVAL. onset to death Years 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 24e. On the basis of examination and /or investiga ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ 'vas ❑ : onset to de Mb onset to death onset to death;' 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES No 21c. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO ZIP CODE' 24d. TIME PRONOUNCED DEAD CD