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' 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 />