' STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RA/SED SEAL OF THE MEBRASKA HF.�4tTHAND HUMAN �RVICES
<br />SYSTEM, IT CERT/FIES THE BELOW TD BE A TRUE COPY OF THE ORIGIN�64. RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH dND HUMAN SERVICE'S SYSTEM, VITAL STATdSTICS SECT/0N, UI�HICH /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ��
<br />�
<br />aare o� �ssuan►cE � p� 2 0 8 6 7 3
<br />• NOV O�T LOCJ� ASS/STANT STATE REGISTAAR
<br />UNCOLN, NEBRASKA HEALTH AND HUMAN SERVICES
<br />STATE OF NEBRQSKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SURPORT
<br />CERTIPICATE OF DEATH
<br />�� ' 1. DECEPENT'S-NAME (Flrst, Middle, Leat, Sufflx) , 2. SEX 3.DATEOFDEATH (Mo.,Day,Yr.)
<br />.r' Debra Jo Weitzel Female October 30, 2006
<br />;��
<br />�r�:;;'; 4. CITY AND 3TATE OR TERRI70RY, OR FOREION COUNTRY OF BIRTH 6e. AOE-Laet Blrthdey 5b. UNDER 1 YEAR 6c. UNDER 1 DAY 6. DATE OF BIRTH (MO., Dey, YrJ
<br />_� (Yw.) MOS. DAYS HOURS MIN9.
<br />��` Humboldt, Nebraska. 50 February 24, 1956
<br />!��+;'1 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />�� 505-74-1862 G9$ I,: ❑ Inpatlent g� ❑ Nuratr�gHameiLTC ❑HospicreFecl�ry
<br />�; 8b. FACILITY-NAME (If not Inatilutlon, give etreet end numbel) ❑ EFi/Outpetlent (.�DacedenYaHome
<br />-s ?
<br />>�°''' 41.96 Arizona Avenue __
<br />; - - ------ -
<br /> .. � .' . . .. _. - ❑ prn ❑ ott,er (3Pec(h')
<br />'�R���?�� 8d. COUNTY OF DEATH
<br /> ',��,�-i Ba CITY ORTOWN OF DEATH (Include Zip Code)
<br />� ' Grand Island 68803 Ha11
<br />��, Ba.HE81DENCE-STAfE 8b.00UNTY 9o.CITYORTOWN
<br />'° Nebraska Hall Grand Island
<br />,`$';%
<br />ed. STREETAND NUMBER 9e. APT. NO 9t. Z1P CODE 88� 1NS1DE CITY LIMITS
<br />,� � 4196 Arizona Avenue 68$03 �YES a r�o
<br />�' 10a. MARITAL STATUS A7TIME OF DEATH �0 Marrled Never Merrled 10b. NAME OF BPOUSE (Firal, Mlddle, Last, SutOx) li wite, gNe melden neme.
<br />'}
<br />'-''�•,'�verried,tiutseparated ❑Widowed ❑oworoed ❑unknown ROUBTt WB�tZ�l.
<br />��,
<br />11. FATHEH'9•NAME (Flrat, Middle, Last, Sufflx) 12, MOTHER'H-NAME (First, Mlddle, Maiden 9umame)
<br />:�'��
<br />,o_�, Harlan D. Cas ers Elenora Hogrefe
<br />13. EVER IN U.3. ARMED FORCES? Qfve dates ot aervice H yea. 14a. INFORMANT NAME 14b. PELATI0N3HI P TO DECEDENT
<br />,�� +;,. (Yes� no, or unk.) NO
<br />Robert Weitzel Husband
<br />i 16. METHOD OF DISP031TION 18a EMBALMERSIONATURE 186. LICENSE N0. 18c. DATE (Mo., Day, Yr. )
<br />❑suaai ❑oo�aeon Not Embalmed October 31, 2006
<br />� 1 � Crematlon ❑ Entom6ment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br />❑pemoval ❑Other(Spectfy� y�estlawn. Memorial Park Crematory Grand Island Nebraska
<br />`''-. 17&FUNERALHOMENAMEANDMAILINGADDRESS (S1f88t,CNyorTOVm,State) 17b.ZIpCode
<br />Livingston-Sondermann Funeral Home, 601 I3. Webb Rd., Grand Island, NE 68803
<br />" � r� �'�� �6� SE A�' dtH�,S�e:�instkGetion e i : ' ` ;,
<br />18. PART I. Enter the chain at evenis--0iaeases, irtJudes, or cromplicetions•-thet dlrectiy coused 1he death. DO NOT enter terminal eaente such ea cardlao erteat, APPROXIMATE INTERVAL,
<br />1
<br />respiratory aneat, or v�nMcular flb�liatlon wilhout ahowi� Ihe edologq. DO NOT ABBREVIATE. Enler only one cause on a Iina Add addiUonel tlnea H necesaery. �
<br />IMMEDIATE CAUSE � �set to dealh
<br />I
<br />� I
<br />IMb1ED1ATECAUSE(fltml ��)
<br />ms�seoT�diUonr�Wlfi9 DUET0,0 ASACONSEQUENCEOF: I onsetrodeath
<br />in dealh) I
<br />��e�� ro� Lymphoma Cancer ;January 20Q5
<br />�� ��� � ��� � DUE T0, pR A3 A CONSEQUENCE OF: i onaet to death
<br />on Ilne e. i
<br />ENettheUNDERI.YMOCAUSE �
<br />(dlseaseorin�urythatinitiated �°� z i
<br />thaeveMsresultingindeath) pUETO,ORA3ACONSEDUENCEOF. t onsettodeath
<br />1A41' �
<br />i�I �
<br />t i 18. PART II.OTHER SIONIFICANT CONDITIONS�Conditiana contribuling to the death but not resulting In the underlying ceuee glven tn PART l, A& MEDICAIEXAMINER
<br />OR CORONER CONTACTED9
<br />�] YES ❑ NO
<br />O.IFFEMALE: 2.MANNEROFDEATH 2 IFTRANSPORTATIONINJURY c.WASANAUTOPSYPERFORMED7
<br />�� Nol pregnant wllhin paet year �] Netural ❑ HomtcWe ❑ DrivadOperaror
<br />. V `' ❑ Pregnent at 1lme o1 death ❑ Accldenl0 Pending Im�esUgetion
<br />❑ Pessenger Q YES X] NO
<br />� ❑ Not pregnant, bN pregnent within 42 days of death ❑ Pedestden g�d. WERE AUTOPSY FINDINa9 AVNLABLE TO
<br />c,: 0 6uicide ❑ Could nol be tletermined
<br />`.� Not pregnem, buI pregrrent 43 deys to 1 year before death ❑ Other (3peolty) �pp,�p���SE OF DEATH7
<br />; O Unknown H pregnent wilhfn the past year O YES Q NO
<br />�, 22a. DATE OF INJURV (Mo., Dey,Yc) 22b.SIME OF INJURY 22a. PLACE OF iNJURY-At Bome, larm, sireef, lectory, o�ice bullding, conaUuctlon aite, etc. (3peciry)
<br />-- -- - -
<br />� ---�-------- ` - =_ --= m
<br />�� 22d.INJURYATWOflK7 22e.DESCRIBEHOWINJURYOCCURRED
<br />❑ YE6 ❑ NO
<br />22f. LOCATION OF INJURY • STREET @ NUMBEp, APT. N0. CRY/fOWN SViTE Z1P CODE
<br />23a. DATE OFDEATH (Mo., pey,YC) . DATE SI�NED (Mo., Oay, Yc)
<br />'; �� October 30, 20Q6 .��� Ctobi
<br />_�' �
<br />y 23b. DATE SI6NED (Mo., Day,Yr.) 23c.TIMEOF DEATH ��� . P�ONi
<br />Ea m n 'm a '' J L I
<br />'' $�� 23d. To the beat of my knowledge, dealh occurred et 1he tlme, date and plaoe � u�i �� e. On the
<br />.o � end due to the ceuse(s) steted. (Signature and Title �� .� p � the tln
<br />`� $ o
<br />.�ID70BACCOUSECONTRIBUTETOTHEDEATH? .HASORaANORTIS8UE00NAT1�N8
<br />❑ YES NO ❑ PflOBABLY 0 UNKNOWN ❑ YE3 � NO
<br />.NAME,TffLEANDADpRE&90FCERTIFIER (PHYSICIAN,CORONER'3PHYSICIANORCOUNTYATTORNEI� (rypea
<br />'.'arbara Christine Dunn, Deputy Hall County Attorney
<br />- 1 2ea.aEatsraaa�sstaNarut� �
<br />(Mo.. Day,Yr.)
<br />ptace and due to the
<br />TIME OF�DEATH
<br />:30 p m
<br />TIME PRONOUNCED DEAD
<br />:30 n m
<br />m. in mv oninion deeth axurtad at
<br />�
<br />�
<br />iEREO? �¢6. WAS CONSENT GRANTED7
<br />N ot Appllceble It 28a is NO ❑ YES ❑ NO
<br />31 S. Locust Street Grand Isla d, NE
<br />288. DATE FILED BY RE�ISTHAR (Mo., Dey, Yr.)
<br />�o� s zoos
<br />
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