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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />3/16/2021
<br />LINCOLN, NEBRASKA
<br />202102390
<br />,41.444
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR 'I
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />21 03163
<br />at the time of di
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<br />1, DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Lavonne Dorothy Lee
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 5, 2021
<br />Roseland, Nebraska
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />82
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />T. SOCIAL SECURITY NUMBER
<br />50844-7219
<br />8b: FACILITY•NAME (If not Institution, give street and number)
<br />1632 Coventry Lane
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />February 24, 1939
<br />OTHER 0 Nursing Home/LTC
<br />E Decedent's Home
<br />0 Other (Specify)
<br />Hospice Facility::
<br />8e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER
<br />1632 Coventry Lane
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g -f INSIDE CITY LIMITS
<br />L81 YES O NO
<br />10a, MARITAL. STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />James Kenneth Lee
<br />11, FATHER'S•NAME (First, Middle, Last, Suffix)
<br />Ervin Mangers''
<br />12. MOTHER'S -NAME (First,
<br />Martha Beiriger
<br />Middle, Maiden Surname)
<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 />James Kenneth Lee
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑Donation
<br />lM Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16e. DATE (Mo., Day, Yr.)
<br />March 7, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths FUneral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b, Zip Cods
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />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,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />IMMEDIATE CAUSE (Final
<br />dtaease or condition.: resulting
<br />in -death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)Congestive Heart Failure
<br />any, leading to the causelisted
<br />ort lines.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNOERLVINGCAUSE c) Interstitial Lung Disease
<br />(disease or injury met Initiated
<br />the events resulting in death)
<br />LAST
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />1 Day
<br />onset to death
<br />1 Year
<br />onset todeath
<br />8 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />IS. PA II, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />20. IF. FEMALE:
<br />Not pregnant within past year
<br />QPregnant at time Of death
<br />Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown If pregnant wihin the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />DYES ONO
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident ❑ Pending investigation
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />© Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES (]NO.
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ONO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta (Specly)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />0.
<br />0
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 5, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 5, 2021
<br />23c. TIME OF DEATH
<br />12:06 PM
<br />23d, To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Isaac J. Berg, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑
<br />YES ® NO 0 PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR SSUE r
<br />❑ YES E7
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />zip CODE
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation, in my opinion death =caned at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />ATION BEEN CONSIDERED?
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES
<br />28a. REGISTRAR'S SIGNATURE( 3at_rzaji 8
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 10, 2021
<br />
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