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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN...SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ~1;fiiiJ:?mg~WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlS1!1CS:BEtfiDiil/'WH1t:H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . =.^;..~)t~I..'. ~..'....~7t.~.':.:-...;~.~~~:..' -;.;~c..
<br />
<br />DATE OF ISSUANCE '..: ~;. ~~ ~\
<br />t-:: ~_; .i. ~'.'=:;:::.s:..=..~ ::: --. .:-::
<br />JUN 272006 2008071,19
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />'\ STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND-~.HP~;[f6:" 2'&.sl5 4
<br /> CERTIFICATE OF DEATH-~=_, . = .,' .
<br />~ .".
<br /> 1. DECEDENT'S.NAME (First, Middle, Lasl, Sulllx) 2.SEX 3. DATEOFiJ-EATH (Mo.. Day, Yr.)
<br /> LeRoy Alfred Dempsay Male June 18,2006
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE. Last Birthday 6b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. D~!;()F BIRTH. (Mo.. Day. Yr.)
<br /> (Yrs.) MOS. I DAYS HOURS I MINS.
<br /> Coleridge, Nebraska 54 March 4, 1952
<br /> 7. SOCIAL SECURITY NUMBER Sa, PLACE OF DEATH
<br />" 507-68-3980 ~: iii Inpallenl QJJ:!EB: o Nursing Home/LTC o Hospice Faclllly
<br /> '-'
<br /> 0: Sb. FACILlTY.NAME (II not Institution, give slreet and number) [J ERIOulpallenl o Decedent'S Home
<br /> G
<br /> ~ Saint Francis Medical Center Oa>\ o Olher(Speclfy)
<br /> i5 8c. CITY OR TOWN OF DEATH (Include Zip Code) 18d. COUNTY OF DEATH
<br /> ..J
<br /> <(
<br /> 0: Grand Island 68803 Hall
<br /> w
<br /> z 9a. RESIDENCE-STATE 19b. COUNTY 19c. CITY OR TOWN
<br /> ~
<br /> j Nebraska Hall Grand Island
<br /> " 9d. STREET AND NUMBER I ge, APT. NO 191. ZIP CODE I 9g.INSIDE CITY LIMITS
<br /> J!
<br /> 'E 3408 Graham Ave 68803 IjI YES 0 NO
<br /> ;:.
<br /> ~ lOa. MARITAL STATUS AT TIME OF DEATH iii Married [1 Never Married lOb, NAME OF SPOUSE (First, Middle, Lasl, SUlllx) II wile, give maiden name.
<br /> is. o Marned, bulseparaled 0 Widowed o Divorced 0 Unknown
<br /> E Judith MaePeck
<br /> 8
<br /> il!l 11. FATHER'S.NAME (Flrsl, Mtddle, Lasll Sulllx) 112. MOTHER'S.NAME (First, Middle, Malden Surname)
<br /> {? Ralph Demosav ' Florence. Taqqart
<br /> 13. EVER IN U.S. ARMED FORCES? Give dales 01 service II yes'114a.INFOAMANT.NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, no, or unk.) No Judith Mae Dempsay Wife
<br /> 15. METHOD OF DISPOSITION 16a. E ALMER'SI1U~~ T6b. LICENSE NO. 16c. DATE (MO.. Day, Yr. )
<br /> o Bullal o Donalion ( - !Aj)(l1ll- . . V" 1328 June.)3,., 2006
<br /> 12!1 Cremanon o Entombmenl led. CEMETEIJ, CREMATORY OR ~ER LOCATION CITY / TOWN STATE
<br /> o Removal o Other (SpecIIY)
<br /> Central Nebraska Creamation Service Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel. City orTown, Stale~ 117b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, ebraska 68801
<br /> CAUSE OF DEATH (See instructions snd examples)
<br /> 19. PART I. Enlerthe chain 01 evenls--dlseases,lnjulleS, or compllcatlons-.tnal directly caused the deatn. DO NOT enler lermlnal evenls such as cardIac arresl, APPROXIMATE INTERVAL
<br /> I
<br /> resplralory arresl. orventrlcularflbrillallon wllnout showing Ihe enology. DO NOT ABBREVIATE,. Enleronly one cause on a line. Add addlUonalllnes II necessary. I
<br /> IMMEDIATE CAUSE: I onsel to dealn
<br /> /1, f1(U-..4(;t 'h~ C<t II( C/AJ I
<br /> la) 7t1 e fa 5k~v I ~ tl}e$So
<br /> IMMEDIATE CAUSE (Fh.1
<br /> al..... or cOl1dRlonr.SURlng DUE TO. OR AS A CONSEQUENCE OF: I onselto dealh
<br /> n de.lh) I
<br /> (h) I
<br /> Sequentlelly 11.1 condlllon., II I
<br /> eny, le.dlng 10 lhecau..llcled DUE TO, OR AS A CONSEQUENCE OF: I onsello deatn
<br /> on IIn... I
<br /> Enter.,. UNDERLYING CAUSE I
<br /> (dleeale or Injury Ih.tlnlllaled (c)
<br /> lhe .venlt reluRlng n de.th) OUE TO. OR AS A CONSEQUENCE OF: I onsel to dealn
<br /> \J6f I
<br /> (d) I
<br /> Ie. PART II. OTHER SIGNIFICANT CONDITIONS. Conditions conll1butlng 10 Ine dealh bul not resulllng In the underlying caUse given In PART I. 19. WAS MEDICAL EXAMINER
<br /> 71~ OR CORONER CONTACTED?
<br /> o YES )/21' NO
<br /> 0: 20. IF FEMALE: 21a.MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 210. WAS AN AUTOPSY PERFORMED?
<br /> W Xl Natural 0 Homicide o Driver/Operator
<br /> y; o Nol pregnanl within past yeer
<br /> Ii: o Passenger DYES ..it NO
<br /> W o Pregnanl al time 01 dealh o AccldenlO Pending Invesngatlon
<br /> lJ o pedestrian
<br /> j o Not pregnant, bul pregnant wllnln 42 d.ys 01 deeth o Suicide 0 Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> 11 o Not pregnanl, bul pregnant 43 days to 1 yearbelore death o Other (Speclly) COMPLETE CAUSE OF DEATH?
<br /> li 0. Unknown II pregnant wllhln the pasl year DYES ONO
<br /> is.
<br /> E I 22b. TIME OF INJURYm !22C. PLACE OF INJURY.AI home, larm, slreel, laclory. olnoe bulldlng, conotlUCtlon olle, etc, (Specify)
<br /> 0 22a, DATE OF INJURY (Mo., Day, Yr.)
<br /> lJ
<br /> il!l
<br /> {? 22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br /> DYES 0 NO
<br /> 221. LOCATION OF INJURV. STREET & NUMBER, APT. NO. CITYnowN STATE ZIP CODE
<br /> 23a. DATE OF DEAnl (Mo., Day, Yr.) ~~fij 24a. DATE SIGNED (Mo.. Day, Yr,) 24b. TIME OF DEATH
<br /> 1;~ June 18. 2006 m
<br /> '512 i;;;~
<br /> o;~ 23b. OATE SIGNED (Mo., Day, Yr.) I 23c. TIME OF DEATH ;;~l: 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> 'ii:I:::; ~U IV ..:ll I ;1 t:V(; 09:02 A.m o.D.4(~ m
<br /> Ell.z ~..~z
<br /> 8 go 23d. To the beSl 01 my knowledge, dealn occurred althe time, dale .nd place ffizO 24e, On the basis 01 examlnanon and/or Invesllgallon, in my opinion deatn occurred al
<br /> 0>'6 and due to Ine cause(s) stated. (Slgnalure and Title)" o>z:J the time, date and place and due to Ine oause(s) .t.ted. (Slgnatule and Title) "
<br /> "'c "'00
<br /> ~~ ///:./2 - A~iI i~i - tUfJ ~a::U
<br /> 80
<br /> 26. DID TOBACCO USE CONTRIBUTE TO THE fl(ATH? 126a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? I 26b. WAS CONSENT GRANTED?
<br /> DYES )lI NO o PROBABLY [J UNKNOWN o YES ,'It NO Nol Applicable 1126a Is NO 0 YES o NO
<br />U 27. NAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pnnl)
<br />/ Richard Fruehling, M.D. 2116 w. Faidley Ave.#400,Grand Island, Nebraska 68803
<br />OC ~ 28a. REGISTRAR'S SIGNATURE Ah.. ~7f" A. ~. 28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br /> JUN 23 2006
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