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r <br />STATE OF NEBRASKA <br />�9=� •�� �;� �. <br />WHEIN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT�1 �IN�H�IM/d11� S�RVICES, IT CERTIFIES <br />THE f�ELOW TD BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE RIEBQA��(Ad��.PARTM�IVT,=QF J�EALTH ANO <br />HUMAN SERVICES, 1/ITAL RECORDS �OFFICE, WHICH IS THE LEGAL DEPOSITORY FOI�'V�I,L••ii�j �f��� �' '. f <br />, � � � � <br />� � � <br />DATEOFISSUAIdCE y - T . � � <br />* <br />� U Z��9 � �T . @�' G�7P� �`� . ��.Y .' ; <br />A��jANT SgTs4T�E ��STll�3 y� x � <br />LIN NEBR,4SKA � O� 1 O O!! J N� ��MEIV7' OE5 EAL� H��� � �; { <br />�4 � c^ �,- . - �& «°° �. <br />' . 4 � q � o� �� ,� ' , ���� 't �« ' 't' <br />m : <br />� � � � '���,! � `�� "�i : ;�� �. , <br />. � " , . �.�"'�' <br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN 6ERVICES FINANCE AND SUPPO �' ''�° '`s <br />CERTIFICATE OF DEATH � , <br />��t; 1.OECEDENTS•NAME (Firet, Middle, Lest, SuHixJ , 2.8EX 3.DATEOF�EATH (Ma,Day,Yr.) <br />"� , Gerald Lee Leitschuck Male bctober 12, 2009 <br />�+� � <br />i�t� 4.CIlY AND STATE OR'PERRITORY, OR FOREI�N COLLWTRY OF BIRTH 5e. AQELaeI Birthday 6h. UNOEH 1 YEAH 6c. UNQEH 1 DAY B. DATE OF BIRTH (MO., Day,Yr.) � <br />;� r{t <br />(Yre.) td09. DAYS HOURS 6AIN8. <br />'`�`� Pawnee Gity, Nebraska 74 November 3, 1934 • <br />;;;�; <br />r � 7.$OCIALSECURii`/MlIr�BER Ba.PLACEOFDEATH <br />��a 505-42�1550 tiO�piTA�: Cimveuem � ❑NursingHomeRTC OHosn�ceFadmy <br />,N ? 8b. FACIUTY•NAME (If not inet0ution, plve etreet and numbe� � ERlOulpeqent ❑'DacadenPeHome <br />*I�G� , <br />�` St. Fran4,is Medical Center <br />❑ ODa O Ourer(Spedfy) <br />OD <br />r! Bc. CITY ORTOWN QF D TH (Ivclutle Zlp Code) . - � 8d. COUNTY OF DEATH , .. . <br />Grand �,sland 68803 Hall <br />,�: 88.RE810ENCESTATE 9b. COUMY �. CIIY ORTOWN <br />���}' Nebraska Hail Grand Island <br />�� 9�.87REETANDNUMB � Be.APT.NO Bf.LPCADE Bg.INSIDECRYLIMRB <br />u <br />'- - -_,_�.. __.�-„ - .'_...,-__�.-? ---`"_- _ -- - � --..�. �_J� -�-NO -- -- - � <br />225 Ara�}ahoe Ave. - - -- _ -�- �884� -� <br />S Y - - _ � ___ <br />�; tda. MARITAL BTATUS A �TIME OF DEATH � Menled ❑ Never Merried 10b. NAME OF SPOUBE {Flret, MMdle, Laet, 9uHlx) If w8e, give meiden nAme. ' <br />� � <br />,�� O Merrfed, Eutseparatet' O Widowed; ❑ Dlvoroed 0 Unknown Berdena Naber <br />� � 1). FATHER'8•NAME (First, Mlddle, Leat, Sulflx) 12, d10THER'8•NAME (Flrst, mlddle; Maiden Sumame) <br />�� �Willi�m Leitschuck Ro�e Martin � <br />'��" 1�. EYER IN U.3. ARMED FORCE87 �Ive datesof service if y�. 14a.INFORMANT-NAME 1 h. RELATIONSHIP TO DECEDENT <br />��4 <br />r� �t�a,�o,o���k.> ;No Berdena Leitschuck � Wife <br />�;���,�; � . <br />�`+,� 16.METHODOFDISPp3ITI0N 1BaEb1 •SIGNATU t6b.LICENSENO. 1�c.DATE (Mo.,Dey,Yc) <br />' �'� tXa�a� ❑Do'qatlon � �g October 16, 2009 <br />,. � . <br />� � i6dCEM ,CHE�dAT0AY0 ERLQCATION CITY/TOWN STATE <br />Nµ �;; ❑CremaUan ❑Entombment <br />��' <br />�; ORemovel oou�a��s�o�ry� y�estlawa Memorial Park Cemeterq Grand Isl,�arad, NE <br />,A , <br />.� <br />�"#� 1�a. FUNERAL HOME NAME AND MAILINp ADDHESS (Sheel, City orTown, Stete) ' 17b. Zip Code <br />Apfel Fun�ral Home, 1123 West 5econd, Grand Island. NE 68801 <br />?,�:.. r4 �,�.�. -��;: d-� F,�s. -} � � .t` W. � ��T �89�._� E��21I{� $�12�-� d71Y 8 - �-� .� '-�"-t g � A nr .r <br />. �->�� .l� 1 ?�, � P� .�. { � ��-:. r � �., �. <br />t 1 PARTI.Enterthe -dlseasea,trijurles,orcompllceUons-thetdlrecllycausedlhedeath.DONOTenterterminaleventssucheacerdlacarrest, MPROXIMATEINTERVAL <br />*� � i . <br />� reBptrerory arreal, or d,¢qtrlcuiaz fiDriilatlon wtthout showing Ne eUOlogy. DUNOTABBREYIATE. Erder only one cause on a Ipre. Add addittonel Wres 0 nec�ssery. � i <br />{ _. . ' I � . <br />_ - IMMEDIATECAUSE i orisettodeaffi <br />J'� ,;,� c�severe multiple blunt force trauma to head and neck' �2 ho es � <br />� '. ����I�B DUETO,ORASACONSEQUENCEOF: � � � oreettodeath <br />ak � I�dea6�) �, � <br />i <br />`� � �tIe1�Ylletcondltlmj�,R �@) � � i <br />�,�_� �y �A����� OUETO,ORASACONSE�UENCEOF. � i � � i onsettodeath <br />�"� dn lbrea <br />� �fheUNDFAI`IQJOCAI�9E �.. � <br />'�''c (dlse�eminJurytlietlnitiatetl (°) � <br />�i�a t�aeventereaWNngNdea�) � <br />DUETO,ORASACONSEQUENCEOF. � I oneettndeaN <br />:�`��F'., � i <br />:�.;�K�,.j .. , ' <br />'�=`';- ,i �dI <br />c <br />t�� 18. PART II.OiHER 8I0 , IFICANT CO{VDIiIONS�COndttlons contribuGng to the death bul nW resuUing in the underlyin8 ��e given in PART I.. ,18. WAS MEDICAL EXAM19INER <br />"%� �' � � OR CORONER CANTACTEDT <br />�� ' � � <br />,i - <br />3 �, � C� YES ❑ NO <br />�, 24.IFFEMALE: - -- - 2T8=MANNEROFbEATFi� - � -. ZiD.IFTRANSPORTATIQNINJl7RY EtO.IMAS�ANA1ffOP3YPFFFUPA9ED4 -� -- <br />C Not Pregnent within p�at year ❑ NeW�I ❑ Homiclde � Drl�edOperaror - . <br />��? W Pregnenlettimeotdeatb �p���Op�g��ygg�A�� OPessenger � YES ❑NO <br />ia� ;:. O PBdesUlBn <br />;�r C�1 Notpregnant,butpre�entwilhln42deysofdealh ❑��qd9 OCOWdnotbadetermined 21¢WEREAUTOPSYFINDIN6SAdAILA8LET0 <br />- ?�; �1 N�P�BB��LbutP�eB48M43deyatotyeerbefore8eath OOttrer(SPedty) COMPLETECAUSEOFDFNH7 <br />� '` �,1 Unknownitpregnant�yiNlnthepastyear Cj(YES ❑ NO <br />=? � <br />; �,Ea. DATE OF INJURY (Mo., Day, Yc) 226. TIME OF INJURY 22c: PLACE OF INJUR1=At home, farm, eheet, factory, ottice buildinp, co�tructinn sile, e�. (Spedly) <br />��� 0�� tober 12 '�'� 2 09 •� a'" nty <br />��� 22d.INJURY/iTWORK? �,� 22a.DESCRIBEHOWINJURYOCCURRED <br />.z3:`J ' <br />. ❑ YES �, NO <br />4� <br />�21.LOCATIONOFINJURY-STREE7'&NUMBER,API:NO: pttlfOWN S�E ZIPCODE <br />e'y I ili <br />a 4: <br />�'r � 23a. DATE OF D�EATH (Mo., Dey, Yc) -� � ,24a. UA7@ SIaNEO (Mo., Dfly, Yr.) � � 246.'il 0 DEA , � <br />3 e : <br />k� S I C g'� � ,. 3 m <br />� �� 23b.DATESI�t��D (Mo.,Day,Yt.) 23o.TIMEOFDEATH � 24c.PRONOUNCEDDEAD (Mo.,Dey,Yr.► 24d.TIA4EPROPIOUNCEDDEAD <br />�,���� � ;; m ��a� October 12 20U9 id:0 a m <br />��. � 23d. To the best cf rtry knowtedga, deaih acourted ffi tha tlm& date emf plece ��� 24e. n the baels of examinatlon ami/or Inveatlgatlon, in my opinfon death acurced at <br />� r ` �' end due to,�Ae cause(e) stated. (8lgnatiue end Title )♦ � $ e time, da ce e d e to tha ceuse s stated. (Signature emlTitle )♦ <br />a F �� ��� �C�ief Deputy Hall <br />: �:�,� <br />F � „ <br />` ?,�.DIDTOBACCOUSEC6NTRIBUTETOTHEDEATH? 28a.HASORaANORTI6SUEDONATIONBEENCON9i ERE07 .WABCONSENTfiRANTE04 <br />' '�, ul YES .❑ NO 'I ❑ PROBABLY ❑ UNKNOWN ❑ YES �Q N0. otApplicableit28eteN6 ❑ YES ❑ N0� <br />�� 7.NAME.TI7LEANDAD,¢RESSOFCERTIFlER (PHYSICUW,CORONER'9PHYSICNNORCOUNTYATTOiiNE1� (TypeorPrinq � � . . <br />_Jack Zitterko f, Chief De ut Hall Count �ttorne 231 S. L cust S NE <br />RE�IBTRAR'S 310NATURE ZBb. DATE FlLEO BY REQlSTRAR (ALo., pa}S Yc) 88O 1 <br />lVOV 2 � 2009 <br />! " <br />HHS-8111/Q3(55081) " <br />