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 />
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