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<br />STATE OF NEBRASKA
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<br />WHEN pis copy CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN; SER)/ICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE P ISSUANCE
<br />6/3/2022
<br />LINCOLN,, NEBRASKA
<br />20230028s
<br />202204353
<br />4
<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 NAMEtFirat, Middle, Last, Suffix)
<br />Robert tr )) Levens
<br />4. CITY AND$TATE DR TERRITORY,: OR FOREIGN COUNTRY OF BIRTH
<br />7 SOCIAL SECURITY NiJMBER
<br />5t?6y50-6873
<br />eb FACiLITY•NAME(if not institution, give street and number)
<br />tb
<br />T $ V raq:Uare Cara Center:
<br />Sc. tTY OR TOWP O> MEATH (Include Zip Coda)
<br />Granth lslind 88803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d STREETA#0 NUMBER
<br />215E21stStreeE
<br />STATUS AT TI
<br />wt separates
<br />11 FATHER S>PIAM.E (First,
<br />Alphe N Levene
<br />9b. COUNTY
<br />Hall
<br />6a AGE • LastBirthday
<br />(Yrs.)
<br />DEATH't Married 0 Never Married
<br />Bowed 0 Divorced 0 Unknown
<br />iddle, Last, Suffix)
<br />78
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1f DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF, DEATH
<br />Ho L ❑ npettent
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />22 07455
<br />3. DATE OFDEATH:(Mo„ 044Vr)
<br />May 20,2022
<br />6. DATE O BIRTH ($o., Oayi YY.)
<br />OTHER ® Nursing Home/LTC
<br />Decedent's Anne
<br />Other (Specify).
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801,
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give ins
<br />Sally J Jepson
<br />ag. NIstpe CITY pier a :
<br />f IES. ❑. NO.:>
<br />12.MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Opal M Elstermeier
<br />8
<br />t
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 05/29/1962-05/27/1966
<br />15.MEJ1d0eOF DI$Pos1TION.:
<br />BUi1a) ; ;; ❑ Don;;iliori'
<br />Cremetloe3 ❑ Enlotrtbntt
<br />Removal ? ® Other' (Specify)
<br />cremation
<br />14a. INFORMANT -NAME
<br />Sally J Levene
<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 />ll Faiths: Funeral Home, 2929 S. Locust Street, Grand Island„Nebraska
<br />18. PAR
<br />14b. RELATION$f'BPTODECEDENT'(
<br />SDOuse
<br />18c. DATE....
<br />May 20,'2"
<br />CITY /TOWN
<br />Gibbon
<br />CAUSE OF DEATH (Seeltstriactiors tint examples)
<br />Enter the Chain of events- ViiettaSes, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />at arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Metastatic Prostate Cancer
<br />IMMEDIATECAtjag (Final
<br />disease of CoiWit en rasuidri
<br />hi debti )
<br />Sequentially list conditions, if b)
<br />any IeaCBap to the cause ijete r ...
<br />ontHlaa
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />1, OR AS A CONSEQUENCE OF:
<br />Enter tir8 OND$({LYINO CAUSE C)
<br />(dleaS 4 or injury .that initiated
<br />the events resulting hi death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST .. .._. d)
<br />:STATE
<br />• Nebraska
<br />;1713 ZIRCOde:
<br />rA � Are 114TH
<br />sassf.* Baa
<br />Months
<br />18 PA IOTHER SlGNIFICANTCONDITIONS-Conditions contributing to the death but not re
<br />20. IF.:'.FEMALE:.
<br />...:,:::..:FEMALE:„:,
<br />pregnant zvladit pae[.Xaar
<br />0try..Pregni ,..itorteordeath.:::
<br />❑ Not pregrreni; but pngnarn within42 days of death
<br />Not pregnant, but pregnant 49 days to 1 year baton
<br />Fjnknown:#pfegnan, wlglinthe#lsstyeat
<br />224 ;;OA TL OF# 4,1Ul
<br />(Mo.; Day, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES 0 NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />Accident 0 Pending investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF IN URN*
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f ;3OCATIONOF 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 />May 20.222
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />04:40 AM
<br />Yo the gest otnli : knowledge, death occurred at the time, date and place
<br />anb dui to tlta cause(sistated (Signature and Title)
<br />had Vieth, MD
<br />25. DID TOBACCOUSE CONTRIBUTE TO THE DEATH?
<br />YES :I»J NO, PROBABLY ® UNKNOWN
<br />Ing in the underlying cause given In PART i.
<br />2113. IF: TRANSPORTATION INJURY
<br />© priver/Operator
<br />❑ Passenger
<br />aPedestrian
<br />❑ Other (Specify)
<br />19. WAS 21100 4".4 Et4410 0:0
<br />OR C Es CONTACTEb7''
<br />O
<br />vis: ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />LJ YES j NO
<br />21d.WERE AUTOPSYPI DINGSAYAILABLE
<br />TO COMPLETE; OF DEATH?
<br />❑ YEs NCi
<br />t heme. farm, street, factory, office building, construction
<br />re
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />f i#iL 181
<br />(1X)
<br />24b. TIME OF DEATH
<br />24d. TIME PROMOUNCE. p
<br />24e. pn the basis of examination and/or investlg thin, In my opinion deathoacurred ar
<br />• the time,. date and place and due to the cause(s) stated. (Signature,vtd'f$tte)..
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />2' NAME, TITLE ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MO, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />2613. WAS CONSENT GRANTS
<br />Not Applicable If 28a is NO
<br />:Yes:: CI >
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 31, 2022
<br />
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