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�uw._ 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 ^ / STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF. HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DATE OF ISSUANCE 2/5/2018 LINCOLN, NEBRASKA N CFI CO CO CO 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Leon Duane Roby 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) January 17, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE • Last Birthday (Yra•) 72 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (MO Day, Yr.) March 17, 1945 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -56 -2208 8a. PLACE OF DEATH HOSPITAL El Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY-NAME (If not lnstitution, give street and number) Veterans Affairs Medical Center ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Aida 9d. STREET AND NUMBER 517 Saturn St. 9e. APT. NO. 9f. ZIP CODE 68810 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married © Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Judy Runge 11. FATHER'S -NAME (First, Middle, Last, Suffix) Leo Roby 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Bessie Thesenvitz 13. EVER IN U.S. ARMED FORCES? Give (Yes, No, or Unk.) Yes 11/04/ dates of service if Yes. 965-11/03/1971 14a. INFORMANT -NAME Judy Roby 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial 0 Donation ® Cremation ❑Entombment ❑` Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) January 20, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. 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, APPROXIMATE INTERVAL onset to death Weeks respiratory arrest, Or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: 1 IMMEDIATE CAUSE (Final a) Sepsis disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially lest conditions, it b) Pertussis Weeks any, leading to the cause listed on line a onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Esophageal Cancer 1 Year (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 8. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 'NA 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ' ] Not pregnant twith n past year Pregnant at time of death 0 Net pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH El Natural ❑ Homicide - ❑ Acc ❑ Pending Investigation . ❑ Could be determined ❑ 21b. IF TRANSPORTATION INJURY ' ° Driver /Operator ❑ Passenger ❑ Pedestrian ❑Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CRUSE OFbEATH? ❑ YES ❑" NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? " OYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. CATE OF LI :C M i ;. ...t., y a y, r.) 1 January 17 , 2018 z Y S u g a E rn z ' rc z O w g z 0 Y K D 8 .1z. CATE SIGNED !Ma, D:.•, Vr.1 ` 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 18, 2018 23c. TIME OF DEATH 10:55 PM 24c. PRONOUN DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and clue to the cause(s) stated. (Signature and Title) Tyler J. Vettel, MD 12 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. Dip TOBACCO USE CONTRIBUTE TO THE DEATH? 2 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO X 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Tyler J. Vettel, MD, 2116 W Faidley Ave Ste 400, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /[ - 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) January 25, 2018 �uw._ 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 ^ / STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF. HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DATE OF ISSUANCE 2/5/2018 LINCOLN, NEBRASKA N CFI CO CO CO