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oitOr etakeimmas SII rm i tc ital iiZik f [[tt Fel )t STATE OF NEBRASKA , rq R" 2 .x18.yt'p�taM x[t x> 1, ��qp) ss„.„ V 'k��R'§Xg. z Y f+iY .... ..x�:xv6�i1�S• AVj� `e votawil 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 4/17/2020 LINCOLN, NEBRASKA 202005685 7 /!.' /Lits ,t* SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1, DECEDEN'rs NAME (First, Middle, Last, Suffix) Loraine Ann Liess' 4. CITY ANO STATE OR TERRIT Scotia, Nebraska ORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday (Yrs.) 78 5b. UNDER 1 YEAR 2. SEX Female 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 20 04715 3. DATE OF DEATH (Mo., Day, Yr.) April 12, 2020 8. DATE OF BIRTH (Mo., Day, Yr.) April 27, 1941 T. SOCIAL SECURITY NURSER '508-52 -1073 • Sb FACILITY NAME (If not institution, give street and nunthci) 626 North Custer Ave Be. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 626 North Custer Ave 9b. COUNTY Hall I8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ EPrOutpatient ❑ DOA 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown 9c. CITY OR TOWN Grand Island OTHER 0 Nursing Hocie/LTC rE2 Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH Hall Be. APT. NO. 9f. ZIP CODE 68803 0 Hospice Facility 9g. INSIDE CITY LIMITS YES ❑ No lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Joseph Liess 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ambrose Winfrey 112. MOTHERS -NAME (First, Mabel Lavher Middle, Malden Surname) 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Catherine Dubois 14b. RELATIONSHIP TO DECEDENT Daughter 1b. METHOD OF DISPOSITION ® Buriaf ❑ Donattont 1:1Cremation ❑ Entombment ❑ Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE Gwen K. Hvronemus 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Cemetery 16b. LICENSE NO. 1448 CITY / TOWN Grand Island 16c. DATE (Mo., Day, Yr.) April 15, 2020 STATE Nebraska A • ,2O. IF FEMALE: 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home. 1123 W. 2nd, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 1a. 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, 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: IMMEDIATECAussfinal a)Acute Myeloaenous Leukemia disease or condition resulting: In death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) any, leading to the cause listed. en line DUE TO, OR AS A CONSEQUENCE OF: gnat the UNoexi.v NO CAUSE c) (disease of injury that Initiated 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death 10 (V.cnths onset to death onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST 18. PART II. OTHER SIG Hypertension d) IFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 0 Not pregnant within peat year 0 Pregnant at time of death 1 0 Not pregnant, but pregnant within 42 days of death p0 Not pregnant, but pregnant 43 days to 1 year before death O C 9 Unknown If pregnant wWdn the past year 22a. DATE OF INJURY (Mo., Day, Yr) 21a. MANNER OF DEATH 0 Natural ❑ Homicide 0 Accident 0 Pending Investigation 0 Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 0 Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) I 22d. INJURY AT WORK? 9 DYES ONO rf 22f. LOCATION OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED STREET & NUMBER, APT.NO. CITY/TOWN STATE Zrt:' o 0 23a. DATE OF DEATH (Mo., Day, Yr.) April 12, 2020 23b. DATE SIGNED (Mo., Day, Yr.) Apr), 13, 2020 23e. TIME OF DEATH 10:03 PM 23d. To the hest of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Tale) Rebecca Steinke, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 24e. DATE SIGNED (Mo., Day, Yr.) • re • re Z�zo O z 8 § ti 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examinatlon and/or investigation, In my opinion death occurred at the time, date and place and due to the cause(*) stated. (signature and Title) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES III NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Rebecca Steinke, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28b. WAS CONSENT GRANTED? Not Applicable If 26a is NO D YES ❑ NO 28a. REGISTRAR'S SIGNATURE oc/1a- 11 8<-✓z-P-rr, i-►vr_e.- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 14, 2020 i