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1. DECEDENTS -NAME (First Middle, Lest, Suffix)
<br />Cleona M. Weiser
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 21, 2008
<br />4. CITY AND STATE OR TERITORY, OR FOREIGN COUNTRY OF BIRTH
<br />il
<br />Shelton, NE
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />75
<br />5b. UNDER 1 YEAR
<br />50. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day. Yr.)
<br />May 14, 1932
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />507-38-6285 . ,. ' .. ' .....: _.
<br />Se. PLACE OF DEATH
<br />HOSPITAL IInpatent OTHER: ❑ Nursing Home/LTC UHospice Facility
<br />U ER/Outpatient U Decedent's Home •
<br />0DOA U Other (Specify)
<br />u „p C
<br />Bb. FACIUTY -NAME (If not institution, give street and number)
<br />Good Samaritan Hospital •
<br />,
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Kearney 68847
<br />8d. COUNTY OF DEATH
<br />Buffalo
<br />r ' 9a RESIDENCE -STATE
<br />Nebraska
<br />fib. COUNTY
<br />Buffalo .
<br />9o. CITY OR TOWN
<br />Shelton
<br />9d STREET AIM D NUMBER
<br />145COII St., Box 182
<br />9e. APT. NO
<br />9f. ZIP CODE
<br />68876
<br />9g. INSIDE CITY UMITS
<br />Ni YES J NO
<br />10a. MARITAL STATUS AT TIME OF DEATH C?iMarried° Never Married
<br />U Married, but separated ❑'Widowed U DNorced U Unknown
<br />10b. NAME OF SPOUSE (First Middle, Lost Suffix) If wIe, give maiden name.
<br />Wayne Weiser
<br />11. FATHER'S -NAME (First, Middle, - Last, Suffix)
<br />Henry Bonsack
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Agnes Franks
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service Eyes .
<br />no, or unit.) N
<br />14e. INFORMANT -NAME
<br />Wa Wei
<br />Wayne Weiser
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />S use
<br />15. METHOD OF DISPOSITION
<br />J Burial U Donation
<br />fj/j Cremation U Entombment
<br />U Removal U Other (Specify)
<br />,a
<br />�
<br />16e. EMBALMER -SIG a RE !JJ LT r
<br />M ud7 ( ;1 . , d�l sgo ` 0Mi 6•
<br />16b. ENSE NO.
<br />6
<br />16c. DATE (Mo., Day, Yr.)
<br />March 22, 2008
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Ne. Cremation Ser. Gibbon Nebraska
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />NOV 102014
<br />LINCOLN, NEBRASKA
<br />20. IF FEMALE:
<br />Not pregnant within pest year
<br />J Pregnant at time of death
<br />J Not Pregnant, but pregnant within 42 days of death
<br />U Not Pregnant, but pregnant 43 days to 1 year before death
<br />:1 Unknown if pregnant within the past year
<br />22e. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />;J YES if NO
<br />26. DID TO ,77 0 US
<br />YES NO
<br />28a. REGISTRAR'S SIGNATURE
<br />201407318
<br />STANLEY S COOPER
<br />ASSISTANT ; STATE REGISTRAR
<br />DEPARTMENT OE HEALTH AND
<br />HUMAN SERVICES ..
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SU
<br />CERTIFICATE OF DEATH U 300
<br />23- DATE OF DEATH (Mo., Day, Yr.)
<br />24a DATE SIGNED (Mo., Day, Yr)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of exadnatlon and/or kwedga on, m my opinion death occurred at
<br />the lime, dab and piece and due to the cause(s) dated. (Signature and Tile) v
<br />17e. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, Cky or Town, Stale)
<br />Godberson Mortuary P.O. Box 10 Gibbon, Nebraska
<br />18. PART?. Enter the shillelagh-diseases, injures, or complications-that directly caused the death. DO NOTenterbrndnd events such as cardiac Brad,
<br />respiratory arrest or ventricular kbraallon valiant showing the etiology. DO NOT ABBREVIATE. Enter only one cage on a Ina Add addSonal Ines If necessary.
<br />IMMEDIATE ,CAUSE:
<br />N et ,
<br />Ata49tr qua..
<br />IMMEDIATE CAUSE (Find X (al
<br />In des disease or condition reauklog DUE TO, OR CONSEQUENCE OF:
<br />in death) M ! /
<br />Sequenftyratconditions, if X (b) L %w &iT
<br />any, leading to the cause listed ( J
<br />on linen DUE TO, OR AS A CONSEQUENCE OF:
<br />Eder the UNDERLYING CAUSE
<br />(disease or knew kmtkd teed (c) ' .. ..
<br />the events reading in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(4) :.
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />C' x ct; Av
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />CONTRIBU
<br />iJ PROBABLY i./
<br />22b. TIME OF INJURY
<br />DEATH?
<br />UNKNOWN
<br />21a MANNER OF DEATH
<br />g Natural U Homicide
<br />U Accident LI Pending Investigation
<br />U Suicide U Could not be determined
<br />m
<br />CITY/TOWN
<br />21h rfRANSPORTATION INJURY
<br />U Dr ver /Operator
<br />rJ Passenger
<br />U Pedestrian
<br />U Other (Specify)
<br />26a. HAS ORGAN OR TISSUE DONATION BEE! CONSIDERED1 .... .
<br />J YES NO
<br />27: NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Lissa A. Woodruff, M.D. PO BOx 550 Kearney, NE 6:.'' 8
<br />17b. Zip Code
<br />68840
<br />D YES ENO
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />onset to death
<br />onset to death
<br />•
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />rJYES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />21d WERE AUTOPSY FINDINGS AYABAfLETO
<br />COMPLETE CAUSE OF DEATH?
<br />J YES g NO
<br />22c, PLACE OF INJURY -At home, farm, street, factory, office building, construction sits, eta (Specify)
<br />STATE ZIP CODE
<br />281). WAS' CONSENT.GRANTED ?. _. .
<br />Not Applicable if 260 Is NO .] YES J NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAR 2.4 2008
<br />HHS-61 11103 (55061)
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