|
.44d11011itItIIR
<br />Ile3�. e 5 !f
<br />. I
<br />t, t1 �
<br />d
<br />6144iii111#eea
<br />r�[
<br />4))F
<br />dd(,1e�1144IoI yAiS
<br />Z eir,),1,0,1, o
<br />9Ir iY111"
<br />IIIf111Ikkk
<br />11 >
<br />1 9
<br />191 1 %
<br />d ( I r
<br />1@di
<br />911i
<br />,ael,,,�(1(ISsittlaaa�a..� I illlPlssa.
<br />STATE OF NEBRASKA
<br />i'�aaavAranrr �rytft9911r1ffltAfi
<br />rr rr 1 I rrr r1 Ir
<br />h/ 1 1
<br />111111
<br />N ! 5 11 7 �\
<br />11 1 111119 9! �\1 / 7;
<br />\ 1 1 I) e 1
<br />, rr, 11 I r , n �.� 11 11 i
<br />�'t..e,,,A4T(?lbfivsfi�1�al ..A,At,..Ttllsl.a.ua3.ae, „u,e ! � I
<br />a /Iasfnhi ,,Neh�,irlrlli orc
<br />AySr r�lni "talk et
<br />s/,1u1Nta �
<br />4/YIQ9ALMffrr''I�ry
<br />AWA. r
<br />/))3)dlii{I,y
<br />f`
<br />re
<br />((F
<br />♦, r
<br />11 it
<br />Illi
<br />(I11111111tth
<br />N1NHl/j;D
<br />1))
<br />WHEN THIS G#RY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CtTiFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OP 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 t7f ISSOANCE
<br />613/2€ 22
<br />LINCOLN, NEBRASKA
<br />202204353
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />TATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF. DEATH
<br />a
<br />8
<br />1 DECEDENTS NAME (srst, Middle, Last, Suffix)
<br />Robert llirgll Levene
<br />4. Clri AND:STATE:Oft TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />700CiAL,OE111
<br />'08x80-9873
<br />lM.BER
<br />Sa. AGE -Last Birthday
<br />(Yrs.)
<br />8b, FACILiIf not Institution,
<br />Tiffany Square Care Center
<br />treet and number)
<br />8c OTT OR TOWN OF DEATH (Include Zip Code)
<br />Grand !stand 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<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 />•
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9d1REE' At l3 NUMBER
<br />2:15 E 1st Street
<br />!ga MARTTAI STATUS AT TIME OF DEATH ®Mauled 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHERS -NAME (first, Middle, Last, Suffix)
<br />Alpha N ; Levene
<br />13. EVstt iN U.& ARMED FORCES? Give dates of service if Yes.
<br />unk.) Yes 05/29/1 ,962-05/27/1966
<br />(YA
<br />16, METH
<br />r�+I iPOSITION
<br />1 sf Bttriat [ Ooitation
<br />Cremattoft ❑ Entombment
<br />RsmovaT: ® Other (Specify)
<br />cremation
<br />9c. CITY OR TOWN
<br />Grand., Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATYI (Mo., DayKYr)
<br />May 20, 2L122.:
<br />6. DATE OF BIRfif4'(Mo., Day;'irr.)
<br />January 1t 194 4
<br />OTHER (xI Nursing Home/LT_
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />lob. NAME OF SPOUSE (First, Middle, Last,
<br />Sally J Jepson
<br />14a. INFORMANT NAME
<br />Sally J Levene
<br />EMBALMER -SIGNATURE
<br />Not Embalmed
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE fMITY LIMI`T'S
<br /># yes C o
<br />12 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Opals M Elstermeier
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />lie FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town,: State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />18.P
<br />TI.Enn
<br />pirate
<br />16b. LICENSE NO.
<br />CITY A TOWN
<br />Gibbon
<br />14b. RELATI
<br />Soou8q;
<br />TO IEC@tNT{
<br />16c DATE Ater;
<br />May 20:2I#2e
<br />STAVE
<br />Nebraska
<br />'17b.ZIp Cod*
<br />88801 <.
<br />CAUSE OF DEATH (See Instructions and examples)
<br />of events- 4Hertattee, Injuries, or complications -that directly caused the death. D0 NOT enter terminal events such as cardiac arrest,'
<br />r ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Metastatic Prostate Cancer
<br />IMMEDIATECA[iSie if
<br />disease et feet.. lent;
<br />....... ....... ......... .
<br />in Nafattl9
<br />Sequentially Est conditions, If
<br />any,.lea4Mgtoth..e sause:lieted.
<br />Elitat tlrit:I/I
<br />...................
<br />.................
<br />(diaeaaeuri
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, ORAS AI CONSEQUENCE OF:
<br />I dsath
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PARTtt OT!►ER SIGNIFICANT CONDITIONS -Conditions contributing to the death
<br />20.1F
<br />N
<br />�regmantet tDrw of deattr
<br />❑: Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />1Anttnown ttpxegnarttrin the past year wlg
<br />o;
<br />22a. SATE OF,.I)
<br />(MA. Day, Yr.)
<br />21a. MANNER OF. DEATH
<br />® Natural a Homirlde
<br />❑ Accident ❑ Penning Investigation
<br />0 Suicide 0 Could not be determined
<br />,t not re
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At holm
<br />22e. DESCRIBE' HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 20, 2022
<br />23b. DATE SIGNED (Mo , Day, Yr.)
<br />II/Iav 20 2022
<br />I' knowledge,i.sle
<br />auseis) stated,
<br />had Vieth, MD
<br />gin thelinderlying cause given In PART I.
<br />21b, IF; TRANSPORTATION
<br />QDriv.doperator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />JURY
<br />19. WAS 'MEDICAL En* .. Eft
<br />OR CORONEittoNTACTifi
<br />® YE }: NO
<br />21c. WASIANAUTOPSY 4p?
<br />❑ YES J NO
<br />21d. WERE AUTOPSYPiN�INOS ATLABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES I NO .:,; ... ...
<br />arm, street, factory, office building, construction I
<br />tI?PeQI
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />04:40 AM
<br />h occurred at thetime, date and place !: .
<br />ignature and Title)
<br />2& DID TOBACCO USE:CONTRIBUTE TO THE DEATH?
<br />]YES ❑ ND LJ PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD;.::
<br />e. On his b ais of examination andtor inveedge Ion, In my opinion' d+
<br />the time, date and place and due to the cause(s) stated. (Stgaatut
<br />26a. HAS ORGAN<OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ENO
<br />21. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Feidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED? .
<br />Not Applicable If 26a is NO 13 YE 8
<br />❑ NO
<br />28b. DATE FILED BY REGIS
<br />May 31, 2022
<br />o., Day, Yr.)
<br />
|