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easkYltYy aeiiti mmen.`cmv, &3ara.4miummh r� s(Baa(lomugh..iemgatu i3 .aaaasi 'moi; bat- .,44171 ' NNO;'f° trtawt9unn,1wt VINfroh 14E00 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 12/7/2020 LINCOLN, NEBRASKA 202100172 444. i. et f r SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 20 16662 . DECEDENTSIAME (First, Middle, Last, Suffix) Pearl Elizabeth Leverington 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Rural Custer County, Nebraska 5a. AGE - Last Birthday (Yrs.) 79 5b. UNDER 1 YEAR 2. SEX Female 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr). November 27 2020 6. DATE OF BIRTH (Mo., Day, Yr.) October 11, 194:1 7. SOCIAL SECURI 507.54-4062 NUMBER 8b. FACILITY-NAME'(Ifnot Institution, give street and number) Good Samaritan Society -Grand Island Village 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island OTHER ® Nursing Home/LTC ❑ Decedent's Home 0 Other (Specify) I8d. COUNTY OF DEATH Hall Hospice Facility 9d. STREET AND NUMBER 1220 N Howard Avenue 9e. APT. NO. 9f. ZIP CODE 68803 99. INSIDE CITY LIMITS ad YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Kenneth Warren Leverington 11. FATHERS•NAME (First, Middle, Last, Suffix) George Griffin 1 12. MOTHER'S -NAME (First, Middle, Sophronia Ann Golden Maiden Surname) 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Kenneth Warren Leverington 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑Donation ❑';Crerttatton ❑ Entombment ❑' Removal ' 0 Other (Specify) 16a. EMBALMER -SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) December 4:2020 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Cemetery Grand Island STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Ail Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 18. 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 ABBRkVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Renal Failure disease or condition resulting' Sequentially list conditions, if any, leading to the cause listed on line a Enterthe UNDERLYING CAUSE (disease or Injury that init ated the events resulting In death) LAST DUE TO, OR AS A CONSEQUENCE OF: b)Chronic Kidney Disease DUE TO, OR AS A CONSEQUENCE OF: c) Diabetes Type 2 1Tb. Zip Code 68801 APPROXIMATE INTERVAL onset _tO_death - 1 Month onset to death 8 Years onsettodeath 15 Years DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART Ii. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. CF(F, Metabolic Encephalopathy onset to death 19. WAS MEDICAL OR CORONER CONTACTED? ❑ YES 511 NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑'Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown II pregnant within the pest year 22a. DATE OFINUURY (Mo.:Day, Yr.) 21a. MANNER OF DEATH ® Natural 0 HomIcide ❑ Accident ❑ Pending Investigation 0 Suicide 0 Could not be determined 22b. TIME OF INJURY 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger ❑`Pedestrian ❑ Other(Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ®No 21d. WERE AUTOPSYFINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc (Specify)' 22d. INJURY AT WORK? OYES .❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY . STREET & NUMBER, APT.NO. CITY/TOWN STATE P:GODE is W I Z oy� l i z 0 23a. DATE OF DEATH(Mo., Day, Yr.) November 27, 2020 23b. DATE SIGNED (Mo., Day, Yr.) November 30, 2020 23c. TIME OF DEATH 01:43 PM td. To Nte best oftny-knowledge, death occurred at the time, date and place anti duetothecauae(a) stated. (Signature and Title) Rebecca Steinke, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO 0 PROBABLY ® UNKNOWN 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEA TH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOLNCED DEAD 24e. On the betels of examination and/or Investiga ion, in my opinion death Occurred at the time, date and place and due to the cause(s) elated. (Signature and Title) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO 27. NAME, Irma AND ADDRESS OF CERTIFIER (Type or Print Rebecca Steinke, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NQ 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 30, 2020