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STATE OF NEBRASKA <br /> <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 <br />• f-, ... <br />~ 2 ~- ' <br />r ~ % ' ' ... <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 <br /> <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 <br /> <br /> <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 <br />I <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 <br /> <br />' IMMEDIATE CAUSE: I onset to death <br /> <br />.. x <br />' I ~- <br />. . <br />'~ ~ ~ <br />r ~ mo <br />IMMEDIATECAUSE(Flnel __(a) ~ ~ ~ y ~~ <br /> <br />~~'~~ dteeaaeorcondltbnresuking DUE T0, OR AS A CONSEQUENCE OP: I onset to death <br /> Induth) I <br /> .. <br />,~ <br />~' <br />Spu~ntlslly llet vondl[lone, If (b) ~r u ~~ I ~ ' ` r'"~ (~/' F <br /> <br />_ ; <br />~;,,#• any, keding to the cause Ileted <br />DUE T0, OR AS A C NSEOUENCE OF: I onset to death <br /> r,k' <br />~~ on tins a. <br />` <br /> EntatM UNDERLYING CAUSE <br />~ <br />(c) ~~ <br />~ <br /> <br />~ (dltreaw or ln)ury that initiated <br />~ ~,,, ~ <br />a <br />-..__ '-"-'..° <br />, . <br />7. theevenureeuktnglndrwlh) <br />.--- .-_..-.° <br />DUE TO, OR AS A CONSEQUENCE OF: I onset to death <br /> <br />~F U~Bf <br />I <br /> - (d) I <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 <br /> <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 <br /> <br /> <br />. 22d. DATE 0 <br />F INJURY (Mo., Day, Yr.) <br /> <br />.--_-..~..r _. _ <br />22b. TIME OF INJURY 22c. PLACE bF INJURY•Al home, Isrm, street, factory, office building, ovnatruCllon 6118, etc. (Specfy) <br />m <br />...-......`~_ <br /> <br />22d.INJURYATWORRT - -~........~ <br /> <br />- .. _ ...- _.. <br />22e.IIE50RIBEHOWINJURY000UfiRtrD ~ -~~~ ~ ~ - ~ ~ -- ---- -" ~- ~ ---~ ---- ' <br /> n ^ YES ^ NO ~ _-..- <br />,.. <br /> . <br />.. <br />221. LOCATION DP INJURY • STREET 8 NUMBER, APT. N0. CITVlyDWN STATE ZIP CODE <br /> 4 <br /> w~':,.- 23a, DATE OF DEATH (Mo., Day, Yr,) <br />24a. DATE SIGNED (MO., Day, Yr.) 24b.TIME OP DEATH ' <br />, <br /> _~ $z m <br />b'~ k ~ - t~ - ~v~ <br />~ ' ~~` ~ ~ <br />- 23b. DATE SIGNED (Mv., Day, Yr. ~ C.TIME OF DEATH ~ ~ ~ <br />24c. PRONOUNCED DEAD (Md., Day, Yr.) 24d. TIME PRONOUNCED DEAD <br /> J <br />~ <br />• <br />~ <br /> <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 <br />~ <br />+ and due t0 the cause(s) s led <br />(i nature and Title) • <br />p <br />ih <br />li <br />d <br />t <br />d <br />l <br />h <br /> ~ ~ <br />. <br />a <br />ma, <br />a <br />a en <br />p <br />ace and due to I <br />O <br />a Cauee(9) stated. (Signature and Title) <br />o <br /> • ~a <br /> 6 <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 <br /> ~ ~,~ ~ -- N ~ h~ <br /> 2Ba. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Dey, Yr.) <br /> JAN ~ 2009 <br /> i <br /> <br /> <br />~O~ <br />HHS-61 11/03 (55061) <br />