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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />9/28/2018
<br />LINCOLN, NEBRASKA
<br />r 4 S u3 Fx% / ax Y it
<br />RUSSELL FOSLER ! d 1,
<br />201 900259 INTER M ASSISTANT
<br />DEPARTMENT OF HEALTH STATEREGISTRAR �Ih/141 \
<br />AND HUMAN SERVICES i'``1 9Rcx
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1
<br />812114
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Leland Towne
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 10, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Maywood, Nebraska
<br />(Yrs.)
<br />86
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />May 9, 1932
<br />7. SOCIAL SECURITY NUMBER
<br />506-46-8333
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />�uy2Y.' Od<Vista Q c..0 i.,:and
<br />0 ER/Outpatient ❑ Decedent's Home
<br />0 ()OA Ott;er'Specify ASSISTED LIVING
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />i?.?.. QSCInGurc_STATF 9h COI INTY
<br />Nebraska I Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />214 North Piper
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />❑ Married, but separated El Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First,. Middle, Last, Suffix) If wife, give maiden name
<br />Lois N Spencer
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Towne
<br />12. MOTHERS -NAME (First, Middle, Maiden Surname)
<br />Jessie Barry
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or (Jnk.) Yes 1.10/14/1952-10/12/1954
<br />14a. INFORMANT -NAME
<br />Lynda Lange
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />16b. LICENSE NO.
<br />1411
<br />16c. DATE (Mo., Day, Yr.)
<br />September 14, 2018
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Maywood Cemetery Maywood Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Blase-Wetzel-Strauser Memorial Chapel, 315 Center Ave, PO Box 125. Curtis. Nebraska
<br />17b. Zip Code
<br />69025
<br />CAUSE OF DEATH (See instructions and examples)
<br />19. PART I. Enter the Chain of events- -diseases, injuries, or complications -that directly caused the death. DD NOT enter torminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause 00 a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Multi system Organ Failure
<br />disease or condition resulting
<br />onset to death
<br />Days
<br />in death) n.r R AS . CO eon trCE C7: :
<br />= TO; 0..... N„_..,.- cr.:-.et w .><:=.E
<br />Sequentially list Conditions, if € b)Deme ntia Months
<br />any,: leading to the cause listed
<br />line a.
<br />on
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYiNG CAUSE C/ CalOiOVaSLUIai Disease Months
<br />(disease or injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES El NO
<br />20. IF FEMALE: <
<br />0 Not pregnant within past year
<br />❑Pregnant at time of deathPassenger
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0
<br />21c. WAS AN AUTOPSY PERFORMED?r
<br />0 YES ® NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 clays to 1 year before death
<br />❑;Unknown if pregnant within the past year
<br />0 Suicide iCld not be determined
<br />❑ou
<br />❑ Pedestrian
<br />0 other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?.
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. :INJURY AT WORK? -,=
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 10. 2018
<br />Tot e completed by,
<br />CORONER'S PHYSI ;IAN'
<br />or COJNTY ATTORNEY"
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 13, 2018
<br />23c. TIME OF DEATH24c.
<br />I 03:05 AM
<br />_ _ _ _ _
<br />PRONOUNCED DEAD (Mo., Day, Yr.)
<br />__ _ _
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to .he causes) stated. (oignal..,e and ;Ir..,
<br />Chad Vieth, MD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, acre ana phlox end due to ine cau.e(s) stared. 1Siyuaiure .rtu i .ie)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 11 NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />77 kiAIUF TITI F akin ann0FCC (IF r:FPTIFIFP /Tvna nr Printl
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 24, 2018
<br />
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