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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE ' S <br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY` OF <br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND <br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL. RECORDS <br />TATE OF NEBRASKA, IT <br />THE ORIGINAL RECORD <br />HUMAN SERVICES, VITAL <br />DATE OF ISSUANCE <br />1/8/2018 <br />LINCOLN, NEBRASKA <br />201902258 <br />STANLEY COOPER <br />ASSISTA STATE REGISTRAR <br />DEPARTMENT HEALTH AND <br />HUMAN SERVICES <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />CERTIFICATE OF DEATH <br />To be completed/verified by: FUNERAL DIRECTOR <br />1. DECEDENTS -NAME (First, Middle, Last, Suffix) <br />William George Leiser <br />2. SEX <br />Male <br />3. DATE OF DEATH (Mo., Day, Yr.) <br />December31, 2017 <br />4. CITY AND STATE OR TERRITORY, OR FOREIGNCOUNTRY 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 />Grand Island, Nebraska ` <br />(Yrs.) <br />57 <br />MOS. <br />DAYS <br />HOURS <br />MINS. <br />May 12, 1960 <br />7. SOCIAL SECURITY NUMBER <br />505-88-8639 <br />8a. PLACE OF DEATH <br />HOSP'TAL © Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility <br />C !:-.,....-1. • -... ... <br />Netxaska Medicine <br />n <br />� cwv.:;,aueile L.. ucce:ie^s s r.oi,ie <br />0 DOA ❑ Other (Specify) <br />8c. CITY OR TOWN OF DEATH (Include Zip Code) <br />Omaha 68198 <br />bd. COUNTY OF DEATH <br />Douglas <br />9a. RESIDENCE -STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY OR TOWN <br />Grand Island <br />9d. STREET AND NUMBER <br />5515 North Engleman Road <br />9e. APT. NO. <br />9f. ZIP CODE <br />68803 <br />9g. INSIDE CITY LIMITS <br />® YES 0 NO <br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married <br />Married, but separated 0 Widowed 0 Divorced 9 Unknown <br />10o. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name <br />Sandy Quandt <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />George William Leiser <br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) , <br />Dorothy Ann Donnermeyer <br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. <br />(Yes, No, or Unk.) No <br />14a. INFORMANT -NAME <br />Sandy Leiser <br />14b. RELATIONSHIP. TO DECEDENT, <br />Spouse <br />15. METHOD OF. DISPOSITION <br />❑ Burial 0 Donation <br />16a. EMBALMER -SIGNATURE <br />Not Embalmed <br />16b. LICENSE NO. <br />16c. BATE (Mo., Day, Yr.) <br />January 2, 2018 <br />® Cremation 0 Entombment <br />❑;Removal 0 Other (Specify) <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE <br />Central Nebraska Cremation Services Gibbon Nebraska <br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) <br />ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska <br />17b. Zip Code <br />68801 <br />CAUSE OF DEATHjSee instructions and examples) <br />18. PART 1. Enter the chain of events --diseases, injuries, or complications -that directly caused the death. DO: NOT enter terminal events such as cardiac arrest, APPROXIMATE TERVAL ". <br />To be completed by: CERTIFIER <br />respiratory arrest, or ventricular fibrillation without showing the etiology. DC NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. <br />IMMEDIATE CAUSE: <br />IMMEDIATE CAUSE (Final a) Septic Shock <br />..._ ...,. ...,.. a <br />onset to death <br />3 Days <br />in death) <br />DUE TO, OR AS A CONSEQUENCE OF: <br />Sequentially PMcOnditions,if : b)Diffuse Epidural Abscess With Spinal Cord Infarction <br />any, eading to the tausa fisted <br />on line a. <br />onset to death <br />7 Days <br />_... <br />DUE TO, OR AS A CONSEQUENCE OF: <br />Enter the UNDERLYING CAUSE c) Diabetes Mellitus <br />(Oise.. or injury that initiated <br />onset to death <br />the events resulting m 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; ®'NO <br />20. IF FEMALE: <br />0 Not pregnant withm past year <br />0 Pregnant at time of death <br />21a. MANNER OF DEATH <br />® Natural 0 Homicide <br />0 Accident 0 Pending Investigation <br />21b. IF TRANSPORTATION INJURY <br />0 Driver/Operator <br />❑ Passenger <br />21c. WAS AN AUTOPSY PERFORMED? <br />❑ YES ® NO <br />0 Not pregnant, but pregnant within 02 days of death <br />9 Not pregnant, but pregnant 43 days to 1 year before death <br />0 Unknown if pregnant within the past year <br />El Suicide 0 Could not be determined <br />❑ Pedestrian <br />o 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, <br />farm, street, factory, office building, <br />construction site, etc. (Specify) <br />22d. INJURY <br />OYES <br />AT WORK? <br />❑ NO <br />22e. DESCRIBE HOW INJURY OCCURRED <br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE <br />To be completeC by <br />MEDICAL CERTIF ER <br />ONLY <br />23a. DATE OF DEATH (Mo., Day, Yr.) <br />December31, 2017 <br />To be complete ^I by <br />CORONER'S PHYSICIAN <br />or COUNTY ATTCRNEY <br />ONLY <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24b. TIME OF DEATH <br />23b. DATE SIGNED (Mo., Day, Yr.) <br />January 2, 2018 <br />23c. TIME OF DEATH <br />11:39 PM <br />24c. PRONOUNCED DEAD (Mo., Uay, Ir.) <br />s4a. tilNt rngNJw[..cG uEA <br />3d. To the best of my knowledge, death occur red at the rime, dale and place <br />and due to the cause(s) stated. (Signature and Title) <br />Amol N, Patil, MD <br />24e. On the basis of examination and/or investiga ion, in my opinion death occurred at <br />the time, date and place and due to the cause(s) stated. (Signature and Title) <br />25. DID TOBACCO <br />❑ YES <br />USE CONTRIBUTE TO THE DEATH? <br />0 NO 0 PROBABLY ® UNKNOWN <br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />❑ YES ® NO <br />26b. WAS CONSENT GRANTED? <br />Not Applicable if 26a is NO ❑ YES 0 NO <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print <br />Amol N. Patil, MD, 985990 Nebraska Medical Center, <br />Omaha, Nebraska, 68198 <br />28a. REGISTRAR'S SIGNATURE28b. <br />DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br />January 4, 2018 <br />