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 />
|