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WHEN TISS COPY CARmS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC 6M:iff*CH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 200409397 '"I _ ANLEY S. coOPFR 8/31/2004 ASS15T *nth MTE JMGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES. FINS AND SIi WRT VITAL STATISTICS == a4 09333 CERTIFICATE OF DEATH - 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3: -DATE OF DEATH /Month. Day. Year/ Duane Roger Leibert Male August 22, 2004 4. CITY AND STATE OF BIRTH /t not in U.S.A.. name country/ Sa. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year) MOS. DAYS SL. IRS' MINS Sargent, Nebraska (Yrs.1Sn 5b. G July 2, 1952 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH 505 -66 -4741 HOSPITAL: ❑ Inpatient OTHER: ® Nursing Home ❑ ER Outpatient ❑ Residence 8b. FACILITY -Name (t not institution, give street and number) St. Francis Skilled Care Center ❑ DOA ❑ Other /Speatvi 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island Yes ® - ❑ Hall _ - 9i REST - AYE 96. COUNTY - 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Code/ 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 2550 N. Webb Road 6880 Yes ® No ❑ 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 12. MARRIED ❑WIDOWED 13. NAME OF SPOUSE /ll wi /e, give maiden name) etc.) (Specify) T� White (Specify) A� American. NEVER DIVORCED MARRI Carmen Hafner 14a. USUAL OCCUPATION /Give kind of work done dung most 14b. of working life, evan dretred/ KIND OF BUSINESS INDUS spit t al p 15. EDUCATION )Specify only highest grade completed) EI nta or Gonda 10 -121 College 11 -4 or 5-1 �ti raae Kitchen & Housekeeping VA Medical Center 16. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Roger Leibert Phyllis Carmody 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yes. no. or unk.) (If yes. give war and dates of services) Yes Aug.24,1971 -Au .23,1973 Carmen Leibert 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP) 50 N. Webb Road, Grand Island, Nebraska 68803 B LICENSE NO. - 21 a. METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY NAME /��3 ;izzE SI Burial ❑ Removal Aug. 26, 2004 Grand Island City Cemetery 22a. FUNERAL HOME -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston - Sondermann F.H. ❑Cremation Don.... Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 601 N.. Webb Road, Grand Island, Nebraska 68803 -4050 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b), AND (c)) I Interval between onset and death k PART I I (al r DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death I (c) I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART III IF FEMALE. WAS THERE A 2a AUTOPSY 25. REFERRED TO MEDICAL PREGNANCY IN THE PAST 3 MONTHS? =ASE EXAMINER OR CORONER? (Ages 10 -54) Yes No Yes NO Yes No 26a. 26b. DATE OF INJURY /MO.. Day. Yr.J 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident � Undetermined M Suicide Pending 26e. INJURY AT WORK 26f. PLACE QF INJURY - (Sp AI home, farm. street, factory office budding, eta echy/ 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation ❑❑ Yes No [I 27a. DATE OF DEATH (Mo.. Day. Yr.) 28a. DATE SIGNED (Mo.. Day. Yr) 28b TIME OF DEATH �a August 22, 2004 M 27b. DATE SIGNED Mo.. Da Yr. ( Y 1 X 27c. TIME OF DEATH X 28c. PRONOUNCED DEAD (MO.. Day, Yr.) 28d. PRONOUNCED.DEAD (Hours & "' o $ � < } HS 8 Z� , 04:00 P M ¢ -. z M F g i � ° To the of my kno edge. death occ at the time, date nd place and due to the 28e. On the basis of examination and,or investigation, in my opinion death occurred at causelsl stated. ° B the time, date and place and due to the cause(sl stated. ISi nature and Title) ► (Si nature and Title 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION. BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES ❑ NO �L' OWN ❑ YES DCI NO ❑ YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type a Print) _r Dr. Gordon J. nicek, M.D.,0 729 N. Custer, Grand Island, NE 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Dey. Yr.) AUG 2 7 2004 11