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• 4 �, <br />WHEN THIS COPYCAI�ES THE RAISED SEAL OF THE 1VEBRASKAriH�ALTFI AIYD HUII �l� � <br />SYSTFJY� IT CFRTIF/ES THE BELOW TO BE A TRUE COPY OF THE �R/G/N/fL R�G9�I:! <br />THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEM, VI��1� SrA7��SE�T�1 <br />THE LEOAL DEPOSITORY FOR V1TAL RECORDS = - <br />DATE OF /SSUANCE � �' — <br />_ �, <br />6/2/2 0 04 -�s�sr�►r��r� <br />UNCOLN, NEBRASKA . . HEALTIiAilI�HUMANSL�R�11 <br />STATE OF NEBRASKA- DEPARTMENT OF HEAI TH AND HUMAI+T���INk1� <br />V1TAL S?A'ILSITCS — <br />CERTIFICATE OF DEATH <br />JT-NAME � FIRST � MIDDLE IAST � ' ---�— -� 2 SIX : � <br />i �N1VdIl--- ----__ - <br />4. CITY AND 3TATE OF BiRTH � N�rot fn U.S..9., nema coauuryl Sa AGE � <br />� r�l <br />ManchesteP, En�la�d__ _ <br />7. SOCIAL SECURTIV NUMBER � <br />�07-32-4533 � <br />St. �'a�ancis Medical Ce�ater <br />Bc. CITY. TOWN OR LOCATION OF DEATFi - - - <br />Gran�d Is� � <br />9a RESIDENCE-STA7E Bb. COUNTY <br />Nebra�ka Hall <br />70. RACE - fe.g, Wlilte. Black, American UMian. - 11. ANCEST <br />em.1lS�ecnyl (SVecnvl <br />_W�i_te__ <br />14a USUAL . lGive ldndof wark dane dming mast <br />ol working IHe, avan Nretlradl <br />�1�0�429"� <br />ICH /S <br />`�ALVD SUPPORT <br />� 04 05842 <br />3. DATE OF DEATN fAQa+th Day. Year) <br />IMhday UNDER Y VEAR UNDER 7 DAY & DATE OF BIRTH lMonC4 Day. YearJ <br />6b. MOS pAYS � 5c. HOURS ` MWS. <br />► ' iViay m2, 1925 _ <br />� <br />8a PIACE OF DEATH . ---- -- - . . . __. .- - - � <br />HOSPRAL' � InpetleN OTHER � Nuraing Hane <br />� ❑ �+ ow�vem ❑ a�a�,oe <br />� ooa � ourer Isaecr�vi <br />(IVSIDE CITY L,IMRS ae. courrrr oF oearri <br />Yea � No � I �'d�� . . . - -- <br />. �. C(TY. TOWN OR LOCATfON <br />Grand Y�land <br />ag_ I1elien. Mexican. German, ete) 12 <br />. . 146. KWD OF BU6WESS INDUSTRY <br />,w r..,.,c.,,' r'.,V' �M�} .,..L.. Mnllward . I , <br />1& WAS DECEASm EVER IN U.S."ARMED FOREES7 . . .-- -- - iBe. INFORAIANT- <br />(Yes. no. or unk� I In yes. gire war erid dates W sarvices� ��� <br />I�To --- - -- — - -- -- eorge I <br />18b. INFOHMANT � M/ULINO AOURESS � ISTREET OR R:F.D. NO, CIiY OR TOWN. STi <br />ffi EMB - SIt��WATURE & Ll���-g-�- NO. <br />�/ �I� I //0 • <br />� `L <br />Funer 1� [ome <br />� 9urim � Rmiwval <br />❑ cre�^mm^ ❑ o�m^ <br />NAME QF SPOUSE fU wite. give <br />� DNORCED I GE <br />� <br />_ � _ _ —� EDUCAl]ON. <br />Anna <br />Z76. DATE <br />05/2718004 <br />1`Telbra�k� <br />10•12) <br />OR <br />Yes � No � <br />ne�en nemel <br />npleled) . _ . <br />GoAage Ir-a w s�i <br />SURNAME <br />Weaver <br />- ---- — <br />22b. FUNERAL HOME ADDRESS - �(STREET OR R.P.D. NQ CRY OR TOWN. STATE, ZIP) • <br />32fl3 W 1oTo .i Front St Grand I NE,_68803 ____ ___ <br />23. IMMm1ATE CAUSE ---- ��-- ------- �� ( OWL ONE CAUSE FE.Fi LWH FO(i lal Ibl. �D 1c11 - I � I�ervel �en areel am1 deatn <br />aaar �- ��d �C1 r� fG� I /�/RTGi,��Oh i � 4 � <br />- -- - DUE TO.OR A3 A CONSEQ�IENCE OF ---- - - .- - � �— - - - - - - — . . - - - ----- — - I Irrtarval between oreet ar�d death <br />roi �'i`oY"1v�" ; � <br />DUE TO.OR A3 A CONSEOUENCE OF: -- --.-' -. � . .- . . i ' bePreen onset end deaN <br />���� � ' <br />I — <br />(c� � <br />P � OTIiER SIGNIfiCANT CONDITIONS - CatmHOns contrlbutlng to iha deeth but wt releted � PART III IF FEMALE. WAS THERE A �- E4 AUTOPSY � 2S WAS CASE REFERRED TO NIEDICAL <br />n PREGNANCY W THE PAST 3 MONTHS7 IXAMINER OR CORONER? � <br />n �(�ur �(1�11 �1��Gt�`y <br />f�S �asal v� nm vea rw re$ wo <br />�a V ..._- ---- ZBh. DATE tlF INJURY /Ma /fay. Y�/ 28e. HOUR OF INJURV 28d DESCFUBE HOW IM;JRY OCCURRED . - . .. <br />� Acddent � UMetermhred � . . . M . <br />� Su�ide � ParMing � 28e. INJURY AT WOAK 261. PLACE OF. INJU�RV ` tA M r. farm sVee1 lactay 28g. IOCATION STREEI' OH H.F.D. NO. CRY OR TOWN 9TATE <br />❑ olflce bmltl�ng apecay . <br />Homicide Inveatiga�n Yes � No � <br />27a DATE OF DEATH !Ma Dey. Yr.) - --- --- -__ _� -� _-_- - 28a DATE S16NED (lNa. Day. Yr.l 28b. TIME OF DEATH <br />$ S -z 3- a� �.� � � <br />� �} T/h. DATE S16N /Ma. 0ay. Yr./ 27a TIME OF DEATH f ��� 28a PRONDUNCED DEIW (Ma. Day. Yr.) 28d. PRONWNCED DEAD //+'aurl <br />� . . �`�� �o / � 1�� �� � . <br />�� M � M <br />27d To Ure b�! a( my knowled9e. deeth at itre Nma end p�ace aiM due to ihe r•= �� 2Ba. On Ma hesis o1 ezemination a��m Nv�tlgado4 in my oP�on deaUi occwrad ffi <br />� ce�mels) sfa�. (f .� /1n/� . � � � 8� 9+a tlma dem a�m place and dua m the musels) ateted <br />29. - DID T08ACW USE CONTRIBUTE TO THE DEATFI7 ' � 30.a HA3 OROAN OR TISSUE OONATION BEDV CONSIDEREDT 30.b WAS CONSENT 6F3ANTEDT <br />� YES � NO � � UNKNOWN � YES ��NO � YES � NO <br />---- -- -- ---- ------- ---�� --- - - <br />31.. NAME AND ADDRESS OF CERTffIER (PHVSICUW. CORONEH'S PHYSICIAN OR COUNTY ATTOHNEYI Ryp9OrPrinl) . � . � <br />Gary Settje, M.D. , 2116�'nl' Fa�dley Ave. STE 400, Grand Island NE 68803 <br />r • _ _ -- --- <br />32a REGISTRAR � - - - - - - - - . - - - - ffi6. DATE FlLED BY RE6ISTRAR /Ma Oay. Yi) - ---- - - - <br />-- <br />. <br />J�N - �. 2004 <br />- - ---- - - - - - - - <br />-- - --- - - - - - - <br />- .. -- - . --- - - - - <br />