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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 />_►
<br />DATE OF ISSUANCE *.
<br />202109174
<br />5/5/2020
<br />SARAH BOHNENKAMP
<br />LINCOLN, NEBRASKA
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH 2005511
<br />1. D15CSOENT'S;NAME (First, Middle, Last, Suffix)
<br />2. SEX
<br />3. DATE OF DEATH (Mo., Day,Yr.)
<br />Robert Joseph Lepant
<br />Male
<br />April 27, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />S. DATE OF BIRTH {mo.,'Dsy, Yt.)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />(Yrs.)
<br />Grand Island, Nebraska
<br />58
<br />February 2, 1962
<br />7. SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />re
<br />508.88-8523
<br />HOSPITAL ❑ inpatient OTHER ❑ Nursing Home/LTC [� Hlospits Far/sty
<br />8b. FACILITY-NAME+if not Institution, give street and number)
<br />❑ ER/Outpatient ® Decedent's Home
<br />E
<br />4237 Summer Circle
<br />❑ DOA ❑ Other (Specify)
<br />ec, CITY OR TOWN OF DEATH (include Zip Code)
<br />8d. COUNTY OF DEATH
<br />Grand Island 68803
<br />Hall
<br />)
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />Nebraska
<br />Hall
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />e. APT. NO.
<br />9f. ZIP CODE
<br />4 INSIDE. CITYUMITS
<br />4237 Summer Circle
<br />68803
<br />®YES ❑ N4
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />v
<br />m
<br />r
<br />❑ Married, but separated []Widowed ❑ Divorced ❑ Unknown
<br />Vicki Meade
<br />�+
<br />11. FATHER'S -NAME (fitat, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />3
<br />James Lee Lepant
<br />Kathryn Kelly
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service If Yes.
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />c(Yes,
<br />No, or Unk.) No
<br />Vicki Lepant
<br />Spouse
<br />S
<br />15. METHOD OF DISPOSITION
<br />16a. EMBALMER -SIGNATURE
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />©' Buba/ ❑ Dortaation
<br />Not Embalmed
<br />April 28,2020
<br />Crerrtaltoh' ❑ Entombment
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />iemovai ' ❑Other (Specify)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />17b. Zip Cods
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />68$01
<br />CAUSE OF DEATH See instructions and examples)
<br />18. PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. Do NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />71
<br />IMMEDIATE CAUSE: onset to death
<br />--
<br />IMMEDIATE CAUSE (PI Mal -- a) Metastatic Pancreatic Cancer Week$
<br />disease or condition result
<br />m
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />is
<br />Sequentially list conditions, N b)
<br />marty,
<br />leading to the cause listed
<br />.�
<br />on line A.
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Enter the UNDERLYING CAUSE C)
<br />(dilat*a or injwythatinit(ated
<br />Y
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />S
<br />LAST d)
<br />a.
<br />r
<br />18. PART#. OTHER $iGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />Deep Vein Thrombosis, PE
<br />OR COROt4ERICON TACTED?
<br />A
<br />❑ YES ® NO
<br />0. IF FEMALE;
<br />21a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />© iVotpregnatwtdlhr peat year
<br />® Natural ❑ Homicide
<br />❑ Driver/Operator
<br />C1 YES NO
<br />C] Pregnant at time at depth i
<br />❑ Attidam ❑ Pentling Investigation
<br />❑ Passenger
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />© Not pregoa,d, but pregnant witMn 42 days of deadeath❑Suicide
<br />❑could not be determined
<br />11Pedestrian
<br />a
<br />Not pregnant, but pregnant 48 days to 1 year before death
<br />❑Other (Specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />c
<br />❑ Unknoamlt pregnant within the past year
<br />❑ YES ❑ NO
<br />+
<br />22a. DATE Of tNJURY (Md;; Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site; titt. (Specify)
<br />E
<br />22d. INJURY AT WORK?
<br />HOW INJURY OCCURRED
<br />❑ YES. []NO
<br />rDESCRIBE
<br />r!
<br />#
<br />22f. LOCATION OF INJURY'- STREET & NUMBER, APT.NO. CITY/TOWN STATE 71P. CODE
<br />y iV
<br />'C
<br />23a. DATE OF DEATH (Mo., Day, Yr.)_
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b.
<br />TIME OF DEATH
<br />0
<br />1
<br />S w April 27, 2020
<br />`
<br />.9 _
<br />_1
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d.
<br />TIME PRONOUNCED DEAD
<br />UI
<br />B 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />q' ?.
<br />a
<br />>
<br />'
<br />ri129 2020 09:02 PM
<br />y a
<br />24. On the basis ofexamination and/or Investigation, M my opinion death eccurrad at
<br />me time, date and place and due to the cause(s) stated. (Signature arrd Title)
<br />3d. TO the best of rely knowledge, death occurred at the time, date and piece
<br />E and due tb the tause(s) stated. (Signature and Title)
<br />" 5 �
<br />B
<br />CL
<br />~ Chad Vieth, MD
<br />U
<br />~ Is
<br />25. 010 TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />YES FX] NO ❑ PROBABLY ❑ UNKNOWN
<br />❑ YES ® NO
<br />Not Applicable N 26a is NO ❑YES: ❑ NO
<br />w
<br />27. NAMEOITM AND ADDRESS OF CERTIFIER (Type or Print)
<br />Chad Vieth, Mn; 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />��� ��
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 30, 2020
<br />',
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