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<br />1. DECEDENT -NAME FIRST MIDDLE I LAST
<br />2. SEX
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<br />male
<br />Leonard
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<br />7. SOCIAL SECURTIY NUMBER
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<br />508-30-2587
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<br />❑ ER Outpatient ® Residence
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<br />1928 W. 12th St.
<br />❑ DOA ❑ Otl1e' (specrtvi -
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<br />WHEN THIS COPY CARRES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND M MAN SERVICES
<br />SYSTEAC IT CERTWES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECPV6AIMFt,FWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT1S _ 710k.WHtClfifS_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE 200407389
<br />6/9/2004 ANLEYa- COOPER-
<br />ASSISMW STATE RE61STRAP
<br />LINCOLN, NEBRASKA HEALTH AND HIN MNMRVICES SYSTEIN
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES- f0#jkXAND SUPPDRT
<br />CERTIFICATE OF DEATH - - 04 06131
<br />1. DECEDENT -NAME FIRST MIDDLE I LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />male
<br />Leonard
<br />fzl
<br />May 27, 200A
<br />4. C1 Y AND STATE OF BIRTH tanot n U.S.A.. name country)
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<br />(Yrs. 7 sb.
<br />June 14, 1926
<br />7. SOCIAL SECURTIY NUMBER
<br />aa. PLACE OF DEATH
<br />508-30-2587
<br />HOSPITAL- ❑ Inpadert OTHER ❑ Nursing Hone
<br />-- -
<br />❑ ER Outpatient ® Residence
<br />c
<br />1928 W. 12th St.
<br />❑ DOA ❑ Otl1e' (specrtvi -
<br />Se. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />6e. COUNTY OF DEATH
<br />Grand Island
<br />yesi No ❑
<br />I
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />d. STREET AND NUMBER (IncludingZrp Code)
<br />9e. INSIDE CITY LIMITS
<br />NE
<br />Hall
<br />1-6
<br />Grand Island
<br />1928 W. 12th St.
<br />"
<br />r-
<br />11. ANCESTRY le.g.. Italian. Mexican. Gsrmao, ad)
<br />o
<br />CL
<br />M Ti
<br />CA
<br />..
<br />.Phyllis Jessen
<br />14a. USUAL OCCUPATK)N (Give kind of work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade Competed'
<br />o -�
<br />CD
<br />Elementary or Secondary 10 -12' College'l1 -4 or 5.1
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME'
<br />Ernest Dibbern
<br />Augusta Kroeger
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />T
<br />---,]
<br />Phyllis D i b b e r n
<br />s
<br />1928 W. 12th St. Grand Island, NE 68803
<br />20.E L - SIGNATURE NSE NO.
<br />21a METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY - NAME
<br />1071
<br />29Burial ❑Removal
<br />May 29, .200
<br />m
<br />ERAL NOME - IqA1ME1
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑ Cremation ❑ Donation
<br />Grand Island, M
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE LP)
<br />2929 S. Locust St., Grand Island, NE 68801
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<br />PART
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<br />D !i J
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<br />DUE TO, OF AS A CONSEQUENCE OF: I Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related P ART
<br />III IF FEMALE WAS THERE A 24
<br />AUTOPSY
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<br />EXAMINER OR CORONER?
<br />II
<br />(Ages
<br />10 -541 Yes No
<br />Vas No
<br />Yes NO
<br />26a.
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<br />F-4
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<br />Suicide Pending
<br />260. INJURY AT WORK
<br />-A"". , farm. meet. factory
<br />26f. WkeC EE OF ,I J
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />ollfificc eUdRY
<br />I
<br />27a. DATE OF DEATH (Mo.. Da/y... YYr)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />28b. TIME OF DEATH
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<br />27b. DATE SIGNED (AIO. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMa. Day, Yr.)
<br />28d. PRONOUNCED DEAD plaurl
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<br />27tl. To th at of knowledg . de erred at the time, date and place and due to the
<br />28e. On the basis of examination and,o investigation, in my opinion death occurred at
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<br />eau sl staled.
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<br />S' ature and Title
<br />29, OID TOBACCO USE CONTRIBUTO HE DEA7y.
<br />a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES IJGL NO UNKNOWN
<br />❑ YES NO
<br />❑ YES [XNO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Prntj
<br />C
<br />WHEN THIS COPY CARRES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND M MAN SERVICES
<br />SYSTEAC IT CERTWES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECPV6AIMFt,FWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT1S _ 710k.WHtClfifS_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE 200407389
<br />6/9/2004 ANLEYa- COOPER-
<br />ASSISMW STATE RE61STRAP
<br />LINCOLN, NEBRASKA HEALTH AND HIN MNMRVICES SYSTEIN
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES- f0#jkXAND SUPPDRT
<br />CERTIFICATE OF DEATH - - 04 06131
<br />1. DECEDENT -NAME FIRST MIDDLE I LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />male
<br />Leonard
<br />May 27, 200A
<br />4. C1 Y AND STATE OF BIRTH tanot n U.S.A.. name country)
<br />5a. AGE - last BintldaY
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DAT OF BIRTH / Month. Day. Year)
<br />MOS. I DAYS
<br />So. HOURS' MINE.
<br />OO,d River, NE
<br />(Yrs. 7 sb.
<br />June 14, 1926
<br />7. SOCIAL SECURTIY NUMBER
<br />aa. PLACE OF DEATH
<br />508-30-2587
<br />HOSPITAL- ❑ Inpadert OTHER ❑ Nursing Hone
<br />-- -
<br />❑ ER Outpatient ® Residence
<br />8b. FACILITY -Name (Mnot msNhRion, give eftae/ and number)
<br />1928 W. 12th St.
<br />❑ DOA ❑ Otl1e' (specrtvi -
<br />Se. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />6e. COUNTY OF DEATH
<br />Grand Island
<br />yesi No ❑
<br />I
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />d. STREET AND NUMBER (IncludingZrp Code)
<br />9e. INSIDE CITY LIMITS
<br />NE
<br />Hall
<br />1-6
<br />Grand Island
<br />1928 W. 12th St.
<br />Yes No
<br />10. RACE - (e.g., White. Black. American Malian.
<br />11. ANCESTRY le.g.. Italian. Mexican. Gsrmao, ad)
<br />12. MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE /d wile. give maiden name/
<br />etc.'ISpecify' White
<br />(s°°""'Am e r i c a n
<br />NEVER DIVORCED
<br />FIMARRIED
<br />.Phyllis Jessen
<br />14a. USUAL OCCUPATK)N (Give kind of work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade Competed'
<br />W workmg life, even Nreft ed) operator
<br />Power Plant
<br />Elementary or Secondary 10 -12' College'l1 -4 or 5.1
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME'
<br />Ernest Dibbern
<br />Augusta Kroeger
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />199. INFORMANT - NAME
<br />(Yes' no. °`rip' of yet. give war and dates of s°" tea'
<br />Phyllis D i b b e r n
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />1928 W. 12th St. Grand Island, NE 68803
<br />20.E L - SIGNATURE NSE NO.
<br />21a METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY - NAME
<br />1071
<br />29Burial ❑Removal
<br />May 29, .200
<br />Westlawn cemetery
<br />ERAL NOME - IqA1ME1
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑ Cremation ❑ Donation
<br />Grand Island, M
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE LP)
<br />2929 S. Locust St., Grand Island, NE 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b', AND (q) I Interval between onset and death
<br />PART
<br />, i I
<br />(al I
<br />DUE TO, O CONSEOUENCE OF. I Interval between onset and death
<br />I
<br />I
<br />(b)
<br />DUE TO, OF AS A CONSEQUENCE OF: I Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related P ART
<br />III IF FEMALE WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />II
<br />(Ages
<br />10 -541 Yes No
<br />Vas No
<br />Yes NO
<br />26a.
<br />25b. DATE OF INJURY (Md.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW 114 iJRY OCCURRED
<br />Accident � Undetermined
<br />M
<br />Suicide Pending
<br />260. INJURY AT WORK
<br />-A"". , farm. meet. factory
<br />26f. WkeC EE OF ,I J
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />ollfificc eUdRY
<br />I
<br />27a. DATE OF DEATH (Mo.. Da/y... YYr)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />M
<br />27b. DATE SIGNED (AIO. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD tMa. Day, Yr.)
<br />28d. PRONOUNCED DEAD plaurl
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<br />27tl. To th at of knowledg . de erred at the time, date and place and due to the
<br />28e. On the basis of examination and,o investigation, in my opinion death occurred at
<br />,_
<br />� § 0
<br />eau sl staled.
<br />5 x
<br />the time. date and place and due to the causes' stated.
<br />SS nature and This ► I
<br />S' ature and Title
<br />29, OID TOBACCO USE CONTRIBUTO HE DEA7y.
<br />a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES IJGL NO UNKNOWN
<br />❑ YES NO
<br />❑ YES [XNO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Prntj
<br />Gordon Hrnicek M.D. and SIan} 688D�
<br />_1Nebra„ska
<br />32a. REGISTRAR 32b. DATE FILED BY REGIS1 RAH . Day. Yr./
<br />1 �6m,_7 JUN 8 2004
<br />n- •- -0 -
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