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<br />AfHElrl THIS COPi' CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL. RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OPISSUA. NCE:';
<br />11/20/2021
<br />LINCOLN, NEBRASKA
<br />SARAH BOHNENKAMP
<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
<br />1 DECEDENTS NAME (post, Middle, Last, Suffix)
<br />Leland Roger Davis
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Greeley County, Nebraska
<br />SOt+IAL SECURrrY',NUMBgR
<br />5O5 5,2 487
<br />5a. AGE - La Birthday
<br />(Yrs.)
<br />Sb. FACILITY -NAME (If not institution, give street and number)
<br />CHI Health St. Francis
<br />80
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient.
<br />© ER/Ou patient
<br />❑, DOA,,
<br />tc CITY OR TOW..N OF DEATH (Include 21p Code)
<br />Grand lelanwl 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />* srtiEET AND. NUMBERt
<br />26'23 Jan Street
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />E I t. FATHER'S -NAME (first .:.
<br />1 Dotlald Davis
<br />Middle, Last, Suffix)
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />1t1. METHOD OF,DISPOSITION
<br />❑ aurtat
<br />!C11331iMititn
<br />J Ciremauon, Q Entombment
<br />❑ Removal ❑ Oti1er (fipeeify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 15571
<br />3. DATE OFDEATH iMo,cDsyrYr :,,
<br />November 14; 202-1
<br />6. DATE OF BIRTH(Mo., Day, Yr.)'
<br />Mt
<br />OTHER 0 Nursing Horm
<br />❑ Decedent's Ho
<br />❑ Other(Spectfy
<br />(
<br />8d. COUNTY OF DEATH
<br />Hall
<br />IN. APT. NO.
<br />101a. NAME OF SPOUSE(First " Middle, Last,
<br />Ruby Jane Morrow
<br />14a. INFORMANT -NAME
<br />Ruby Jane Davis
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State):::
<br />A(i
<br />BOB. Funeral Hanle, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions'and examoles)
<br />12. MOTHER'S -NAME (First
<br />Lois Mitchell
<br />16b. LICENSE NO.
<br />Of. ZIP CODE
<br />68803
<br />Sufflx) 11 wife, give maiden name
<br />Middle,
<br />CITY / TOWN
<br />Gibbon
<br />Malden Surname)
<br />14b. RELATIONSHIPTO d NT
<br />Spoufe
<br />16c. DATE`(Ma+YDay,Kr_;)
<br />November
<br />RTI. Enter the chain of events. -diseases,: injuries, or tompfcatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />zpkatory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />TEC U8S{Feral
<br />er condition:. rawaing
<br />Sequentially list conditions, If
<br />spy, Madtn to the mums Ifeted.
<br />Entarttlie UNDERIrNO CAUS(t;
<br />Idiseaseei:tnjury taatinitiatett'
<br />the events resulting in death)
<br />LAST
<br />IMMEDIATE CAUSE:
<br />a) Hypoxic respiratory failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Coyid 19 pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Suspected Bacterial Pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ERVA
<br />18. PART MOTHER SOW/CANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1
<br />. Transtt)tin to Comfort cares and died in hospital
<br />20IF FEMALE:
<br />Not pregnant eyltliin poet yed�;
<br />❑ Pre9nataaltttneardeaue
<br />❑ Net prlrynard, iota prepnam within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown if pregnant within the past year.
<br />22d. INJURY AT WORK?
<br />[]YES [NO
<br />21a. MANNER OF DEATH
<br />®Natural 0 Homicide
<br />❑ Accident ❑ Pending Immetigatiea
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE'.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />t. CATION OF INJURY STREET & NUMBER, APT.NO.
<br />O
<br />O.
<br />(NJ
<br />21b.:❑iW;TRANSPORTATION INJURY
<br />Di1vetCOperator
<br />PaseenQer
<br />Q Pedestrian
<br />❑ Other (Specify)
<br />onset so
<br />Days
<br />onsetto death
<br />10. WAS MEDICAL ;SCANNER.
<br />OR CORONERtNTACTED?`'
<br />❑ YES ', igj NO
<br />21c. WAS AN AUTOPSY
<br />❑ YES 1 N}
<br />21d. WERE AUTOPSY FAVAILABLE'
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />URY-At home,; farm, street, factory, office building, construction:.
<br />23a. DATE'OF. DEATH (Mo., Day,. YO,)
<br />• November 14, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />NQvtmber 1$, 2021 03:29 AM
<br />23d. To the best Qf my idtewledge, death occurred at the time, date and place
<br />and due tothe ire! ee(s) stated. (Signature and Tide)
<br />Michael A. Donner, MD
<br />25. DID TQBACCO;USE CONTRIBUTE TO THE DEATH?
<br />• 0 YES LINO d' PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME
<br />24e. On the bas a of examination and/or Investigation, in my opinion death 444TJj
<br />lite time, date and place and due to the esuse(s) stated. (Sigraittseattti -
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />27. NAME, tTTLE;Ant ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED.
<br />Not Applicable if 26a Is NO 0YOB
<br />28a. REGISTRAR'S SIGNATURE
<br />6k..412 c7.7v.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 17, 2021
<br />
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