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STATE OF NEBRASKA �`
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTK�ND'HFIMAI�I ERVICES, lT. � ERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA�A A�p',ARTi�lER11�b�F HEALTH A1�1 D
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WNICH IS THE LEGAL DEPOSITORY FOR-VIT,A`L'SR. ECORflS�,:� %�; �
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<br />DATE OF ISSUANCE � p� 2 0 5 3 31 ,; � : t • r � r �' ���' , ��i
<br />U5/04/2010 �T�N�EY � GOOPER , ` ;�
<br />2 Q 1 2� L,� 8 6� AS�i'STAN3� SF�ITE R�GISTRAR ; �
<br />DEl�11RTM�'IVT (1FKF�fL7H AND � j �
<br />LINCOLN, NEBRASKA HUIiIAIV S�ERVICES �: Qtr,' .-
<br />..<�„��.•'
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERWICES, �' •!; �' (` �� a. ,:� �,,;"' 1 A 010�d
<br />4
<br />GERTIFIGATE OF DEATIi " � , �, �" ;. .. .. - - - - - -
<br />7. DECEDENT3•NAME (Firat, Middle, Last, SuffUc) 2. SEX �` 3, DAFE OFAEATH (Mo, Day, Yr.)
<br />Ramona Lucille Wemer Female `"�`ApriF 12, 2010
<br />4. ITY AND 3TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last BiRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MO3. DAYS HOURS MINS.
<br />ICairo, Nebraska 91 September 8, 1918
<br />7. $OCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />�505-52-6580 o H SPITAL ❑ InpaUe� OTHER � Nursing Home/LTC � Hosptee Facllity
<br />8b. FACILITY•NAME (If not InsUtuUon, gNe atreet and number)
<br />� ❑ ER/OutpaUent ❑ DecedenYs Home
<br />� 1JVedgewood Care Center ❑ ooA � other (spec�ty)
<br />� 8cr CITY OR TOWN OF DEATH pnclude 21p Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 8a. RESIDENCE�STATE 8b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER 9e. APT. NO. 9F. ZIP CODE 9g. INSIDE CITY UMITS
<br />� 4034 Scheel Drive 68801 � rES ❑ No
<br />� 10a. MARITAL 9TATUS AT TIME OF DEATH � Marrled ❑ Never Mlarrled 10b. NAME OF SPOUSE (Fl�af, Middle, Last, Sufflu) If qrlfe, give malden name
<br />� ❑ nna�ed but separated ❑ v�naowea ❑ nwo►�a ❑ u�� �eRoy Wemer
<br />� 11. FATHER'S•NAME (Flret, Middle, Last, Sufflx) 12. MOTHER'S-NAME (FUst, bUddle, Malden Sumame)
<br />Arthur Tagge Anna Stlenke
<br />�' 13. EVER IN U.S. ARMED FORCES7 Give dates of aervlee H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� (Yea, No, or Unk.) No LeRoy Wemer Husband
<br />,� 7S. METHOD OF DISPOSffION 76a. EMBALMERSIGNATURE 16b. IJCENSE NO. 16c. DATE {Mo., Day, Yr.)
<br />F � Burial ❑ DonaUon
<br />Tracey Dietz 1328 April 21, 2010
<br />❑ CrertmUon Q Entombmerit 16d. CEMETERY, CREMATORY OR OTHER LOCA170N CITY / TOWN STATE
<br />[] Removal ❑ Other (Specify)
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, Sfate) 17b. 2ip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE F DFATH See instructions and exam les
<br />18. PART I. Enter the ehafn oi everrt�-0ISeases, InJuriee, or complieatlon�that tltrecUy eaused fhe death. DO NOT emer temdnel eveMe such ae eaNlaa ertesl, ; APpROXIMATE INTERVAL
<br />�� reepiratory arteat, or verrtricular flbNlledon without show�np ttre etlology. DO NOT qBBREVIATE EMer oNy otre muae on a Ihre. Add addftlonal lhree H necessery.
<br />IMMEDU►TE CAUSE: ; o�et to death
<br />IMMEDIAT6 CAUSE (Final a) Pulmonary Hypertension ; Years
<br />tlisAase or conattion resuwng - -
<br />���'� DUE TO, OR AS A CONSEQUENCE OF: ; o�et to death
<br />S�uentlally tlet eondWona, H b� '
<br />arry, Ieading to the cau� Iieted �
<br />on mre a DUE TO, OR AS A CONSEQUENCE OF: ; o�et to death
<br />�ner nre unroew.nNO cause �1
<br />(dis9eee orinjurythatinlUated
<br />� e� �"� �" �'� DUE TO, OR AS A CONSEQUENCE OF: : onaet to death
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<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-Conditlo� wnMbutl� to the death but not resulG� In the underlying cause givan In PART I. 18. WAS MEDICAL EXANONER
<br />Myelodysplastic Syndrome OR CORONER CONTACTED?
<br />� ❑ ves � No
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. W/`R AN AUTOPSY PERFORMED4
<br />� � Not pregnaM withln p�t year � NaW rel � Homldde � Driverl0perator
<br />v p', P.ee�m � u� or a�, � a:�aaM � PendlnB ImeaNBatlon ❑ PassenBer ❑�s � No
<br />�. Not pregnaM, but prepnaM wNhin 42 dayn o( deatM1 � pedeaoian 21 d. WERE AUTOPSY FINDWGS AVAILABLE
<br />'� �. Not pregnant, but prepnaM 4s days ro 1 year betore death ❑ SulWde � Could nm be determ�ired ��r'$�'�) TO COMPLETE CAUSE OF DEATH?
<br />� �' Unknown H Pre9��� wkhln tha past year ❑ YES ❑ NO
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<br />E 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TId1E OF INJURY 22e. PLACE OF INJURY-At home, farm, street, factory, oftice bWldl�, eorretructlon alte, ete. (Specify)
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<br />.� 22d. INJURYAT WORK? 22e. DESCWBE HOW INJURY OCCURRED
<br />F�
<br />❑ YES ❑ NO
<br />22L LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN 9TATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.� 24b. TIME OF DEATH _
<br />a�' Ap�ll 12� 201 Q ,s ��"
<br />� �,,� 23b. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH ° 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED pEAD
<br />°' � A ril 13, 2010 11:45 PM ��<'
<br />E �t,�Z
<br />$��. � . To the beat of my knowied9e. tleath occurretl at the tlme. date am1 Place �� :
<br />and due M the ca e atated. SI nature sntl Titte • B�� z4e• On fhe basls ot examination antl/or Inveetlgadon, in my opinlon death ��.�k,
<br />���,, �l ) ( 8 1 a � p� Ure Ume. tlale and Place and due to the cause(e) etaled. (SlpnaNre and TIGe) �
<br />~�' Travis S. Hageman, MD '' $ s
<br />25. DID TOBACCO USE CONTWBUTE TO THE DEATH9 26a. WeS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED7
<br />YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES � NO Not AppUcable tf 28a Is NO ❑ YES Q:�VO
<br />2. AMH, TIT D F P , Y R U A (Type or rIM �
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />Aprll 15, 2010
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