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say t STATE OF NEBRASKA MitlinIMORt7-%, ys si.iy4 4,,1 ramik 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 5/8/2018 LINCOLN, NEBRASKA 201806627 STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) LeAnn Lee Clegg 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) April 26, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (MD., Day, Yr.) Grand Island, Nebraska (Yrs.) 78 MOS. DAYS HOURS MINS. August 6, 1939 7. SOCIAL SECURITY NUMBER 508-48-1692 Ba. PLACE OF DEATH HOSPITAL © Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home 0 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 Grand Island y: FUI CO to O CO m Qp D T 0 (f) Z C m 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS (' 1 YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married © Married, but separated ® Widowed ❑ Divorced ❑ Unknown .10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Harry Elden Clegg 11. FATHER'S -NAME (First, Middle, Last, Suffix) William Lorance 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Julia Schwartz 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Caprice Ann Green 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ❑Burial ❑Donation ® Cremation 0 Entombment ❑ Removal ❑ Other(Specify) 16a. EMBALMER -SIGNATURE : Stacie L. Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) May 1, 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 I__I 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, I respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause nn a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute Upper Gastrointestinal Bleed With Shock disease or condition resulting APPROXIMATE INTERVAL onset to death 12 Hours in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list cOnditions, if :. b) Recent Severe Stroke any, leading Co the cause fisted" on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death 3 Weeks onset to death the events resulting in death} DUE TOOR AS A CONSEQUENCE OF: LAST d) , onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO feted by: CERTIFIE c..:o :O V z m 3 ItIII IAa s ,A. n n n 1 ed O R 21a. MANNER OF DEATH El Natural ❑ Homicide Accident Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO El ❑Pending be ❑ Suicide 0 Couldnotdetermined Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES El NO 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? = ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE npleted by CERTIFIER VLY 23a. DATE OF DEATH (Mo., Day, Yr.) April26, 2018 ;; s z 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) April 27, 2018 23c. TIME OF DEATH 08:26 PM 3t E E H ct Z 24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD r 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Richard Freehling, MD 'o' w z O o 6 p 'O o o 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date antl place and due to the causes) stated. (Signature antl Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO El PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 26a. HAS ORGAN OR TISSUE DONATION. BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES 0 NO 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 2, 2018