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A'w'e'q'litidS,�,,�ggggqg . ,. ;4^ ��1��85�441��I�r�re�a((l� ,tivxt(��tti xlxtttty,NtaA> r4tt49f)iilfl'1ftAS9are. . aav4hWJ�N?M 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 RECORDS2 0 2 0 0 8 DATE OF ISSUANCE 10/26/2020 LINCOLN, NEBRASKA 800 sr'12.. 1 & ,i t,►y; SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 20 14171 0 ar E 1a'' V a) V r E 0 S 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jody . Rae Leslie 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) October 13, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Mitchell, South Dakota 5a. AGE - Last Birthday (Yrs.) 61 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 6. DATE OF BIRTH (Mo., Day, Yr.) 7. SOCIAL SECURITY NUMBER 503-72-3639 8b' FACILITY -NAME '(if 'not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island February 14, 1959 OTHER ❑ Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) led. COUNTY OF DEATH Hall 0 Hospice Facility 9d.8TREETAND NUMBER 1412 N Clark Street 9e. APT. NO. 9f. ZIP CODE 68801 !. INSIDE CITY'LIMITS ® YES ❑ NO 10a MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) N wife, give maiden name Terry Lynn Leslie 11, FATHER'S -NAME (First, Middle, Last, Suffix) Terry Lee Sinclair 12. MOTHER'S -NAME (First, Middle, Maiden Surname) I Myrna Lee Weiland 13, EVER IN U,S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Terry Leslie 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial © Donation El Cremation ❑ Entombment Removal ❑ Other (Specify) 16a. EMBALMER -SIGNATURE Brandon S Bachle 16b. LICENSE NO. 1537 16e. DATE (Mo., Day, Yr.) October 21, 2020 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) te. 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. 00 NOT ABBREVIATE. Enter only one cause one line. Add additional lines It necessary. IMMEDIATE CAUSE: a)Acute Hypoxic Respiratory Failure IMMEDIATE CAUSE iFinaf disease or condition muffing in (heath) Sequentially list conditions, if any, leading to the cause listed online a. Enter tter UNDERLYING CAUSE (disease' or injury that initiated the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: blAcute COPD Exacerbation APPROXIMATE INTERVAL onset to death Days DUE TO, OR AS A CONSEQUENCE OF: c) End Stage COPD onset to death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 5, PART S. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. NSTEMI, Metabolic Encephalopathy, Rhinovirus Infection, PVD 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED?' ❑ YES ®NO 20. IF FEMALE; Not pregnant within past: year Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown If pregnant within the past year 21a. MANNER OF DEATH Natural ❑ Homicide 0 Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 0 Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? 0 YES ENO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22e. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8, NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) October 13, 2020 CITY/TOWN 23b. DATE SIGNED (Mo., Day, Yr.) October 20, 2020 23c. TIME OF DEATH 06:00 AM 23d To the best of My knowledge, death occurred at the time, date and place end due to the cause(s) stated. (Signature end Mkt) Suresh Manapuram, MD STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP CODE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or investigation, in my opinion death eccurted at the time, date and place and due to the cause(s) stated. (signature rod Tial).; 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ®NO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? M YES 0 NO •❑ PROBABLY 0 UNKNOWN 2'i, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Suresh Manapuram, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES LJ No.. 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 22, 2020 CD CI 01 CD