STATE OF NEBRASKA
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<br />WHEN THIS CpPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE~AL~H ~I ~p'7+lt61MAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE N~BRA~~C>9~11EF1,9/t7"1~1~'NT pF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL pEPOSITORY FQR f7'~TAt;RgEQ72G1S. '
<br />DATE OF ISSUANCE ,• ~ ~ ~ ~~~
<br />.~ AN a s 209 'STAN,(~'Y,, $, co0~?ER
<br />2 o i o 0 3 o a~ .ASSr~-A~T~~A~~R~~r~TRAR
<br />LINCOLN, NEBRASKA ~•~NUINAN SERVIC~'ALT!-I ,yND
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<br />STATE OF NEEIRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND $UpPO~t "
<br />CERTIFICATE OF DEATH
<br /> 1. DECEDENT'S•NAME (First, Mlddla, Last, Sufllx) ~ 2. SEX 3. DATE OFDEATW(Mo.,Dey,Yr.)
<br /> Leland Donald Rogers Male December 22, 2008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Leat Birthday 5b. UNDER 1 YEAR 5c. UNDER 7 DAY 8. PATE OF BIRTH (Mo., Day, Vr.)
<br /> Holbrook., Nebraska
<br />u (Yrs.) 93 Mos. DAYS Houas MINS. March 20, 1915
<br /> 9e. PLACE OF DEATH _~_.
<br />7. SOCIAL SECURITY NUMBER
<br /> .- 506-46-6890, ld~~:.... ,.,.^ inpatient ~: 7L7 Nureing HameA„TC r^HdepiCefacilhy -~ =
<br /> Sb. fACILITY•NAME (If net Inatliutlon, give aUBet and number)
<br />^ ER/Outpatient ^ Dacedent'eHoma
<br /> T1lfany Square Care Center
<br /> ^ ppq ^Other(Specily)
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Coda) 8d. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> 9e. RESIDENCE•STATE 9h. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> 9d. STREETAND NUMBER 9e. APT. Np 91. ZIP CODE Bg. INSIDE CITY LIMITS
<br /> 31.19 W. Fai.dley Ave.
<br />_ 68803 ~ YES q ND
<br /> 10e. MARITAL STATUS AT TIME OF DEATH ~J Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name.
<br /> ^ Married, but separated ^ widowed ^ Divorced ^ Unknown
<br /> Charlotte Mae Odell
<br /> 17. FATHER'S-NAME (Flret, Middle, Last, Sufllx) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> ~y James-_-.__ . ~0, _ _ Ro ers _ ~_Verl Ellis
<br /> 13. EVER IN U.S. ARMED FORCES? GIvO dates of aerylCe ll yes. 149. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yea, no, orunk.) NO Charlotte Mae Ro ers Souse
<br /> 15. METHOD OF DISPOSITION 16e. E LMER-SIGNATURE 166. LICENSE N0. 18c. DATE (Mo., Day, Yr. )
<br /> yq Bdda ^Donetlon F~~
<br />~. ~uC~ '~ ~ ~'~,~ D m 2008
<br /> L]Crematlan ^ Entombment 15d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^Remvval ^other(spe~dy) Holbrook Cemetery Holbrook, Nebraska
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<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty orTown, State) 17b. Zlp Cade
<br /> `''~' Wenbur Funeral Home, P.o. Box 95, Ara shoe, Nebraska 68922
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<br /> t8. PART I. Enter the Chain of events--diseases, Injuries, or complicatlona••that directly Caused the death. DO NOT enter terminal events such as Cardiac a«eat, APPROXIMATE INTERVAL
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<br /> respiratory erree6 or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add addltlonal Imes II necessary. I
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<br />' IMMEDIATE CAUSE: I onset to death
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<br />IMMEDIATECAUSE(Flnel __(a) ~ ~ ~ y ~~
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<br />~~'~~ dteeaaeorcondltbnresuking DUE T0, OR AS A CONSEQUENCE OP: I onset to death
<br /> Induth) I
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<br />Spu~ntlslly llet vondl[lone, If (b) ~r u ~~ I ~ ' ` r'"~ (~/' F
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<br />~;,,#• any, keding to the cause Ileted
<br />DUE T0, OR AS A C NSEOUENCE OF: I onset to death
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<br /> EntatM UNDERLYING CAUSE
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<br />~ (dltreaw or ln)ury that initiated
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<br />DUE TO, OR AS A CONSEQUENCE OF: I onset to death
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<br /> 19. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing Iv the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> ~ OR CORONER CONTACTED?
<br /> ^ YES ~ NO
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<br />, 2D. IF FEMALE: ~~ 21 a. M
<br />ANNER OF DEATH 21b. IFTRANSPORTATIONINJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />~ 1 0 Not pregnant within pest year ~p
<br />~pNetWel ^HOmlClde ^Driver/Operator x
<br />^ YES ~$
<br /> ^ Pregnant at time of death ^ Accldent^ Panding Investigation
<br />^Pessenger
<br />NO
<br /> ^ Nvl pregnant, but pre nent within 42 da 8 Of death
<br />® Y
<br />^ Sulclde ^ Could not ba determined ^ Pedaelrlen
<br />ltd. WERE AUTOPSY FINDINGS AVAILABLE 7p
<br /> ^ Not pregnant, but pregnant 43 days to 1 year before death ^ Other (Specify) COMPLETE CAUSE OP DEATH?
<br /> U Unknown If pregnant within the pest year
<br />.. ..... ......- --
<br />....._ . ^ vES ^ NO
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<br />. 22d. DATE 0
<br />F INJURY (Mo., Day, Yr.)
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<br />22b. TIME OF INJURY 22c. PLACE bF INJURY•Al home, Isrm, street, factory, office building, ovnatruCllon 6118, etc. (Specfy)
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<br />22d.INJURYATWORRT - -~........~
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<br />22e.IIE50RIBEHOWINJURY000UfiRtrD ~ -~~~ ~ ~ - ~ ~ -- ---- -" ~- ~ ---~ ---- '
<br /> n ^ YES ^ NO ~ _-..-
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<br />221. LOCATION DP INJURY • STREET 8 NUMBER, APT. N0. CITVlyDWN STATE ZIP CODE
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<br /> w~':,.- 23a, DATE OF DEATH (Mo., Day, Yr,)
<br />24a. DATE SIGNED (MO., Day, Yr.) 24b.TIME OP DEATH '
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<br />- 23b. DATE SIGNED (Mv., Day, Yr. ~ C.TIME OF DEATH ~ ~ ~
<br />24c. PRONOUNCED DEAD (Md., Day, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />' 23d. To the best of my knowledge, death occurred at the Ilme,
<br />date and place
<br />w 7~7 248. on the basis of examination andlor Investigation, in my opinion death occurred at
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<br />+ and due t0 the cause(s) s led
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<br />a Cauee(9) stated. (Signature and Title)
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<br /> 25. DIDTOBACCD USE CONTRIBUTE TOTHE DEATH? 28d. HAS ORGAN OR TISSUE
<br />DONATION BEEN CONSIDERED? 26b. WA5 CONSENT GRANTED?
<br /> ~~ 'r ^ YES T~NO Q PROBABLY ^ UNKNOWN ~ ^ YES ~I NO !"Nvl Applicable if 26a is NO ^ YES ^ NO
<br /> X27. Jf~AM,E, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN DR COUNTY ATTORNEY) (Type o~PrjQp
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<br /> 2Ba. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
<br /> JAN ~ 2009
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<br />HHS-61 11/03 (55061)
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