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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN~?,~M.U AN SERVICES; IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA~'l3 P R1~ffbFT t~F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FORT bITA>M.~C~RbE;;? , ••
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<br />DATE OF ISSUANCE
<br />ST.,~!'I~LEY,S. COOPER •,
<br />DEC 3 7, Z00$ AssxsrAn-r~~ar~ R~GIST°;ae~>
<br />LINCOLN, NEBRASKA 2 o i o 0 3 9~ o °U1~1AN SERVD~SyEA~TH:7~~tID: ;
<br />STATE OFNEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FIMANpE'AI~p,S~JPpO ~~\
<br />CERTIFICATE OF DEATH - '~~ ~~~ ~~i a Fi
<br /> 1. DECEDENT'S-NAME (Firer, Middle, Last, Suffix) 2. SEX 3;DgTEOFDEATH (Mo.,Dey,~Yr.)
<br /> Harland Leslie Layher
<br />~ Male December 14, 200$
<br /> 4. CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 56. UNpER 1 YEAR 5c. UNDER 1 DAV 6, DATE OF BIRTH (Mo., Dey, Yr.)
<br /> (Yre.) MOS. DAYS HOURS MINS.
<br /> Grand Island, Nebraska 62 September. 23, 194
<br /> 7.50CIALSECURITYNUMBER Ba.PLA0E0FDEATH
<br /> 505-56-6256
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<br />In a.lent ^ Nur9in Homa/LTC 0
<br />t1QSP_LT9L~ ~ p ' g Hasplce Faculty
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<br />86. FACILITY-NAME (If not institution, glue street end number)
<br /> ^ ER10utpatient ^ Decedent'sWome
<br /> St. Francis Medical Center
<br /> ^ ~,, ^Other(Speclly)
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br /> Grand Island, 68803 _ Hall
<br /> 96. pESIpENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Ha11 Waad River
<br /> 9d.5TREETgNDNUMBER 8e. APT. NO 9f. ZIP CODE 8g. INSIDE CITY LIMITS
<br /> 11962 Wt?st Schultz _ Road 68883 ^ YI=_s ~ No
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ^ Married [Never Merrled _
<br />10b. NAME OF SPOUSE (First, Mlddle, La6t, Suffix) If wife, give maiden name.
<br /> ^ Married, tut separated ^ Wlddwed ^ Olvdreed ^ Unknown
<br /> 11. FATHER'5•NAME (First, Mlddle, Last, Suffix) 12. MOTHER'5•NAME (First, Mlddle, Maiden Surname)
<br /> Lester _ _ Layher Bernice Engel
<br /> 13. EVER IN U
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<br />, ARMED FORCE57 Glve dates of service it yes. 14a.INFORMANT--NAME 146. RELATIONSHIP TO DECEDENT
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<br />(YeYdnlrf)-9-1969 11-2-1970 Kenneth La her Brother
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<br />-_ 15. METHOD OF DISPOSITIDNT 16a. BALMER-5tG A R 18b. LICENSE N0. 18c. DATE (Md., Day, Yr. )
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<br />_k._- _ l~[Burial ^ponation ,(,(~~ /.,~.Z$ December 18, 2008
<br /> ^ Cremation ^ Entombment 16d. CEME RY, CREMATORY R OTHER LOCATION CITY /TOWN STATE
<br /> ^Remaval ^Other(Specify) Waad River Cemetery, Wood River, Nebraska
<br /> 17e. FUNERAL HOME NAME ANO MAILING ADDRESS (Street, City orTown, State) 776. ZIp Code
<br />a.. Apfel Funeral Home, 1123 West Second, Grand Island, NE b880L:„.•..-~..~..
<br /> 18. PART I. Enter the Chain of events••dlssases, In(urles, or compllcaddns••that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
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<br /> respiratory arrest, or ventricular f16rlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add eddltlonel Ilnes I} necessary. I
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<br />-~-;~-, IMMEOIATECAUSE
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<br />IMMEDIATECAUSE(Final (a) '~ ~.l
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<br /> diaeaeeorcondlSonreaulting bUE70,pRA5ACONSEQUENCEO
<br />I oneettodeath
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<br />Sequantlally list candlllOnB, if (6) I
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<br />any,laedingtothecauaelleted DUE TO, ORASACONSEQUENCEOF: I onsattodeath
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<br /> EntertheUNDERLYINGCAUSE
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<br /> (dlaeauorin)urythetlnltlated (c)
<br /> thaeventeresuPonglndealh) DUE TO, ORASACONSEOUENCEOF: I dnsettodeath
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<br />~,~ 18. PART ILOTHER SIGNIFICANT CONDITIONS•Condlllans contributing td the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINEp
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<br />~ ~~ ~ ~ ~ OR CORONERCONTACTED7
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<br />L ^ YES ^ ND
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<br />2D. IF FEMALE:
<br />21 a. MANNER OF DEATH _
<br />21 b. IF TRANSPORTATIONlNJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />^ Not pregnant within pass year ^ Natural ^ Homicide ^ Orlver/Operator
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<br />^ Pregnant at time df death
<br />^ Accident^ Pandidg Investlgatlon
<br />^ Passenger ^YE5 $) NO
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<br />~ ^ Not re Want, but ra Want within 42 da s of death
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<br />^ Suicide ^ Ceuld not be determined ^ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />'{' ^ Nol pregnant, but pregnant 43 days to 1 year before death ^ Other (Specify) COMPLETE CAUSE OF pEATH7
<br />- ^ Unknown if pregnant within the pest year _____ ^YE5 ~ NO
<br /> - 22a. pATE OF INJURY (Me., Day, Yr.) 22b. TIME OFINJURY
<br />m 22c. PLACE OF INJURY•Al home, farm, elreat, factory, oHlce building, conslracpon.site, etC. (Speclry)
<br />'a 22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCGURREp r
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<br />^ YES ^ NO
<br /> 22LLOCATIONDFINJURY-STREET&NUMBER,APT.NO. CfTY/lOWN STATE ZIPGDOE
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<br />ppp~p~i 23a.0ATE F DEATH (Mo., Dey, ~[,)
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<br />~~ .: ~Y u(, _.._._.._.. ~ Y 24a. DATE SIGNED (Mo., Day, Yr.)
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<br />¢ 24b.TIME DF DEATH
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<br /> y~ 23b.DAT $1QNEp(MO.,Day, )
<br />1 23c.TIMEOFbEATW r7i
<br />~~ 24c.PRONOUNCEppEAp(Mo.,pay,Yr.) 24d.TIMEPRONOUNCEDDEAo
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<br /> 23d. To the best of my knowledge, death occurred at thB time, data and place
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<br />th w ~ Q 246.On the basis of examination andlor Invesllgetion, In my opinion death occurred at
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<br />e caul )state (Signature end Title) • a p ~ the time, date and place and due to the cause(s) stated. (Signature and Title)
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<br /> 25.DIpTOBACCOUSECONTRIBUTETOTHEDE
<br />ATH? 28a.HASORGANORTISSUEOONATIONBEENCONSIDERED7 28b.WASCONSENTGRANTE07
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<br />_ ^ yE3 U NO ^ PROBABLY L~J'[1NKNOWN ^YE5 ~ Not Applicable i1 28a Is
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<br />0 ^ YES ^~~
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<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br /> Kimberly A. Micksls M.D. 729 N. Cuter Ave., Grand Island, NE. 68$03
<br /> 28a. REGISTRAR'S SIGNATURE 2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
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<br />DEC i g zoos
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