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WIF WHEN THIS . COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE ON FILE WITH RECORDS OFFICE, DATE OF ISSUANCE 10/25/2016 LINCOLN NEBRASKA Segq!tlnialiy 1191 ce tli ons, rf any, Leading tp the Cause hated on line a. - -- DOCUMENT BELOW TO BE ''<A TRUE COPY OF THE ORIGINAL RECORD THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DUE TO, OR AS A CONSEQUENCE OF: b)Giiobias oma ivluitiforme 201607825 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE, OF DEATH ate STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 8b, FACILITY -NAME (If not Institution, give street and number) EY O P 0 Golden LivirigCenter -Grand Island Lakeview Rc. CITY CS TOWN OF DEFT'? (Include Zip Coda) _ Grand Island 68801 J 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Gerrald Lee Weedin 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Aurora, Nebraska 7. SOCIAL. SECURITY NUMBER 489 -36 -5177 9a. RESIDENCE -STATE Nebraska 5a. AGE - Last Birthday (Yrs.) 9b. COUNTY Hall MOS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9d. STREET AND NUMBER 1924 N. Sherman Blvd 10a. MARITAL STATUS AT;TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Kenneth Weedin 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) No 15. METHOD OF DISPOSITION ❑ Buriat 0 Donation El Cremation ❑ Entombment Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed Sb. UNDER 1 YEAR DAYS HOURS 8d. COUNTY OF DEATH Hall 9c. CITY OR Grand'1 TOWN sland` 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY MINS. OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68803 14a, INFORMANT-NAME -. Audrey Ellen Weedin b. LICENSE NO. 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island.' Nebraska 3. DATE OF DEATH (Mo., Day, Yr.) October 18, 2016 February 21, 6. DATE OF BIRTH (Mo., Day, Yr.) ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Audrey El en Reisinger 12. MOTHER'S -NAME (First, Middle, Lucille Marler Maiden Surname) 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) October 20, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 3 Days 17b, ZipCode 68801 CAUSE OF DEATH (See instructions and examples) APPROXIMATEINTERVAL . ta: PART I. Enter thechain of events- -diseases, injuries, or complications -that directly caused the death. 00 NOT entet terminal events such as cardiac arrest, respiratory arrest, or ventnyeiar fibrillation without showing the etiology. 00 NOT ABBREVIATE. Entet only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting kt:deathl;:: onset to death 2 Pilos onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) ;)disease Or injury :tttat initiated:. the events resulting in death( • EAST:::. DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 2o. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Na1 pregnant, put pregnant within 42 days of death ❑ Net pregnant urx pregnant 43 d ays toy 1 year before death ❑ Whknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 3a DATE OF DEATH (Mo., Day, Yr.) October 18 2016 2*. DAVE SIGNED (Mt ., Day, 'Yr.) October 18, 2016 22d. INJURY AT WORK? 0 YES 0 NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 22b. TIME OF INJURY Tivic OF C'cATr? 07:08 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Isaac J. Berg, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES El NO ❑ PROBABLY ❑ UNKNOWN 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ could not be determined CITY/TOWN 21b. IF TRANSPORTATION ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ()that (Specify) INJURY 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 21c. WAS AN AUTOPSY PERFORMED ❑VES 10 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED STATE ZIP CODE 2 ). 24a. DATE SIGNED (Mo., Day, Yr.) 124b. TIME OF DEATH 1 1, `i Z. 24c. PRONOUNCED DEAD IMo., Day. Yr,ll 24d. TIME PRONOUNCED DEAD c o w 24e. On the basis of examination and/or investigation, in my opinion' death occurred at 2 the time, date and place and due to the cause(s) stated. (Signature and Title) H w V U :a 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES l NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ED NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD,, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /( 28b. DATE FILED BY REGISTRAR (Ma ,Day, Yn) October 24, 2016