|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTHAND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI~-9'ad!HICN lS
<br />THE LEGAL DEPOS/TORY FOR VITAL RECORDS. - ~ -
<br />DATE OF ISSUANCE __ ~ ~`
<br />JUN 12 2007 ((~~ i C~ i =-----~~ T~uuLErs. LDbf~R
<br />LINCOLN, NEBRASKA 2r Q O a7 O ~ 1 V +' }/~,~~AND HUMAN SER~IG
<br />PP~~p~~'' - -r
<br />STATE t?F NE:BRASKA- DEPARTMENT OF HEALTH ANp HUMAN SERVICES FINAN6E AID SLIP _
<br />CERTIFICATE OF DEATH ~_~ _ _ _:. -.~.1:~~~~ 5 7 ~ 7
<br />
<br /> 1.DECEDENT'5-NAME (First, Middle, Lest, Sulfiz) 2. SEX 3. DATE OF DEATH(Mo.,Day,Yr.)
<br /> Gar LeR__o Leece Male Ma 23 2007
<br />
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. ApE•Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY _
<br />e. oATE DP RIRTH (Mo., Day, Yr.) Y
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Grand Island, Nebraska
<br />T 60 August 29, 1946
<br /> 7. SOCIAL SEGURITY NUMBER 8a. PLACE OF DEATW
<br /> S 0 S - 5 2 - 4 9 3 8 _ I10SPJ7B4: 131 Inpatient 4IUEB ^ Nursing Homa/LTC ^ Hospice Facility
<br /> 8b. FACILITY•NAME (It not institution, give street and number) ~„) ER/Outpetlent ^ Decedent'sHome
<br /> St. Frar~iS Medical Center ^ ~ ^Other(Spaciiy)
<br /> 8c. CITV OR TOWN OF pSA7H (Include Zip Code) 8d. COUNTY OF DEATH
<br /> Grand Island _ Hall
<br /> Be. RESIDENCE•STATE Bb. COUNTY _
<br />9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> gd. STREETANDNUMBER 9e. APT. NO gf. ZIP CODE Bg. INSIDE CITY LIMITS
<br /> 3027 Brentwood Place 68801 ~ YES ^ NO
<br /> toe. MARITAL STATUS ATTIME OF DEATH ~Marrled ^ Never Merrled _
<br />lob. NAME OF SPOUSE (First, Middle, Last, Sufllx) II wife, glue melden name.
<br /> ^Manied,butseparatad ^Wldowed UDlvorced ^Unknown
<br />~ arlene Marie Penes
<br /> 11. FATHER'S•NAME
<br />(Pirst, Middls, Lest, Suffix) ~~ 12. MOTHER'S-NAME (First, Midtlle, Maiden Surname)
<br /> Billy LeRoy Leece
<br />- _._...~ Viola Maxine Galusha
<br /> 13. EVER IN U.S. ARMEp FORCES? Give dates of service ii yes. 14a.INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, no, or unk.) NQ ~_ MarlE?11e Leece ife
<br /> 15. METHOD OF DISPOSITION 18a.FMBALMER-SIGNATURE
<br />~ ~ 166. LICENSE N0. 16c. DATE (Mo., pay, Yr. )
<br /> ^Burlal ©Donatltln Npt Embalmed Ma 24 2007
<br /> C~Crematibn ^ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Central Nebraska Cremation Service Gibbon, NE
<br /> 17e. FUNERAL HOME NAME ANO MAILING ADDRESS (Street, Clty orTown, State) ~~ 17b. Zip Code
<br /> Solt Funeral Haute; 1507 17th Street; Central City, NE 58826
<br />'fix ~ 18. PART I. Enter the chain of events-•dlseases, injuries, or eompllee6ons--that directly caused the death. DO NOT enter terminel events such as cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br /> respiratory arrest, or vantrlcular fl6rllletlon without showing the etitlldgy. 00NOT A88REVIAT
<br />E. Enter only one cause on a Ilne. Ad
<br />~dditidnal lines if necessary, l
<br />d
<br /> .~L~ I onset to death
<br />/
<br />J
<br />/
<br />IMMEDIATE CAUSE: / /rL~_ / ~1.4+r'" !~G" -_ `
<br />a
<br /> ..
<br />)
<br />IMMEDIATECAUSE(Flnal (
<br /> dlsesas or cvndldon resulting DUE TO,OR A5ACONSEQUENCE OP: I onset to death
<br /> In deMh)
<br />I
<br /> Sequent(ally Ilat condltlone, If (b) I
<br />I
<br />
<br />~ _
<br />any, kedtng to the cauae listed pUE TO, OR ASACONSEOUENCE OF: ~. ~ I ansat to death
<br />.,~ onllnea.
<br />I
<br /> EMSrtha UNOERLYIN~ CAUSE
<br /> (dlaeaaeorln)urythatlnltlatad (o) I
<br />I
<br />_
<br />- -
<br /> the everda resulting in death)
<br />""""•'°'~'"
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />I onset tc death
<br /> LP6~
<br />I
<br /> (d) I
<br /> 18. PART IL OTHER SIGNIFICANT CONDI710NS•Conditions contrl6uting to the death but not resulting in the underlying cause given In PART I. iB. WAS MEDICAL EXAMINER
<br /> Q~~ OR CORONER CONTACTED?
<br /> ! ^ YES ^ NO
<br /> 20. IF FEMALE: 21e.MANNEROFDEATH ~ 21 b. IFTRANSPORTA7IONINJURY 21c.wA5ANAUTOPSYPERFORMED?
<br /> ^ Not pregnant within past year ^ Natural ^ Homicide ^ DrivarlOparator
<br /> ^ Pregnant at time of death EI Accident^ Panding Investigation
<br />^Paseenger
<br />^ YES I$NO
<br />
<br />^ Not pregnant, but pregnant within 42 days df death
<br />^ Suicide ^ Could not be determined a Pedestrlen
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> ^ Not re nant, but re nant 43 da s to 1 ear before death
<br />P o P 9 y Y ^ Other (Specify)
<br />COMPLETECAUSEOFDEATH7
<br /> ^ Unknown if pregnant within the past year l' YES Q[ NO
<br /> _ 22a. DATE OF INJURY IMo., Dey, YrJ _ _226. TIME_OF INJURY
<br />m 22c..P.LACE OF INJURY•A~home farm strget taGtorv___:___off~e 6ulldlag~no~UJlFtbasLre,~1C. (Specfy/).
<br />~__ - -
<br /> 22d.INJURVATW0RK7 22e.DESCRIBEHOWINJURY000URRED ~~
<br /> ^ YES [] NO
<br /> 22L LOCATION OF INJURY • STREET A NUMBER, APT. N0. l CITY?OWN SiA7E ZIP CODE
<br />~
<br />_ 23a. DATE OF DEATH (Md., Day, Yr.) r 24a. PATE SIGNED (Mo., Day,Yr.) 246.TIME OF DEATH
<br /> s~ m
<br />May 23, 2007
<br />~~ = Ma 2 200
<br /> y _
<br />__,-_-_
<br />23b. DATE SIGNED (Mo., Day, Vr.) J 23o.TIME OF DEATH ~ _ ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />~ ~aPO m 63a~a= a ~ m
<br />•
<br />;
<br />~ ° 9
<br />~ ~ 23d. To the best of my knowledge, death cccurred al the time, date end place r+ w ~ ~ 24e. On t e a Is of a eminetlon and/or Inve ' atI
<br />,' my opinion ath occurred at
<br />and due to the cause(s) stated. (5lgnature and Title) r g iT5 ~ t~ ~ e fe ace and due to cau st to SI re and T' le) ~
<br />- a $ ° (/,,+
<br /> 25. DID TOBACCOU~SECONTRIBUTETOTHFDEATH7 26a.HASpRGANORTISSUEDONATIONBEENCONSIDERED? 286.W CONSENTGRANTEO?~'
<br />/
<br /> ^
<br />^
<br />^
<br />m
<br />/
<br /> YES U7 NO
<br />PR08ABLY
<br />UNKNOWN V
<br />'
<br />Y
<br />ES ^ NO Not Applicable if 26a is NO U YES ©NO
<br /> Y7. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTYATTORNEY) (Type or PrinQ
<br />`~~ William J. Lawton, M.D., 2444 W. Faidle Grand Island NE 68802-0550
<br /> 28a. REGISTRAR'S $IONATURE 28b. DATE FILED BV REpISTRAR (MO., Day, Yr.)
<br /> ~,Y ~ s zoo?
<br />
<br />
|