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WHEN THIS COPYCARRWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOOD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA ­WREW710NI, -WF#CH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - <br />DATE OF ISSUANCE` <br />MAR 21 2000 ATA '"�` `R ' <br />NT 8iA74 <br />LINCOLN, NEBRASKA HEALTH AND- lUMAI1 M!;; 4 - M <br />200106264 <br />u <br />STA-M OF XMWASIU• DWAU#Mff of 1 AL= AND Hum" SMviQs� <br />CExIicnT o DEATH 97 13453 <br />1. DECEDEM •FWrt FIRST - MIDDLE LAST - <br />2 SEX °. '.. <br />? DATE OF DEATH i"wl Dar W1,•I. - - _. <br />Elaine Joy Wieck <br />Female <br />November 5, 1997 <br />s CITYANIDStATEOPOIRM ATAFFFI USA. ,MM *ftP l , - - <br />Sa AGE - La, B.Mry <br />UNDER T YEAR <br />tMaDER T OAY a DATE OF 911"H IAATAR Qer r s+l <br />w MOS pArS: <br />- Victoria, Texas ". <br />(Wa1 <br />57 <br />sc NOUfLS.... MW$ <br />1 November 8, 1939 <br />2 SOGW 3fGJRiR .. <br />M. PLACE OF DEATH <br />4b7 -56 =3705 <br />!�T_A� El w�or.. OTHER (N N.V. <br />❑ ER Oywrn' ❑ Raawel+ce <br />BO FACW,PWM 1rmommoeercvl+wae &"Moe" <br />St: Francis" Skilled Care Center <br />❑ °0A ❑ o.N•'sPKA <br />8G CITY. T0RN0RwrATMOFOEATM._ <br />w #Mm CITY LIMITS <br />M COUNTY OF DEATH <br />Grand Island <br />Y40 ® N° ❑ <br />Hall <br />ft ABSQENCE•FATE _a - <br />k CRY TOWNORLOCATON. 9 STREETANDNLMIBER Ia1cAA.I,Sv C~ <br />9e a51DE CITY LAWS <br />Nebraska "` Hall <br />Grand Island Via Como' 68803 <br />Y» ®"� ❑ <br />RACE • I*& TRIM 7j0' AAIwI[ VW*ft L <br />11. ANCESTRY N4. NArL W.Kark aft! - <br />12. a MARRIED ❑ *1"411 <br />13 NAME OF SPOUSE 0IrAr ww -w%- nam,l <br />White <br />ISw+n American <br />"ErtR O DRCED <br />1 Richard Wieck <br />14 USUALOCCVATION IDI.e'Mtl0I.A11R AruA.rq nlaa, <br />d+trAY9MM am /I,IIq <br />14 KNCOF BL"*SS.WDUATRv p <br />- <br />O. <br />15. EDUCATION ISPecM WAO gI1010 ~1 <br />EkeWWY tr.SKaMaq '0 12T dYW �1 �o e•, <br />Teacher \5 <br />_ <br />College /High School <br />1� years <br />14 FATHER -NAME FIRST MIDDLE : LAST <br />i7 MOTHER FIRST - MIDDLE MAIDEN SURNAME <br />Richard" Dsllas Hodges <br />Valerie HFler. Griffith <br />14 WAS DEBASED <br />EVER. ML U.S. ARMED FORCES' - <br />I% INFORMANT • NAME <br />re; <br />a M'M lnkl <br />rR •w V+wOro ereadsw eeal <br />- - <br />Ricbard Wieck _. <br />11A INFORMANT MI11LINUALIMMbB Iiit4tl uRwe M. nM.+wIY{/I iL/lTN �IwIt [n <br />22 Via Como, Grand Island, Ne. 68803 <br />20 ANOALMER •S"ATUNEIII LICENSE NO. 21e.METHODOFDISPOSTIpN. 210 DATE 121c CEMETERY ORCREMATURt NAMI.._ <br />3 ®B1.w ❑Re nrr Nov. $, 1997 Westlawn Memorial Park <br />22a FUNERAL MOME•NMFE 210 CEMETERY OR CREMATORY LOCATION Ctt'I OP TOWN SIAiF <br />Livingston - Sondermann F.H. El C... ❑°°aw" Grand Island, Nebraska <br />220 FUNERAL. HOME ADDRESS (STREET OR FLVD. NO. CITY OR TOWN. STATE, 7" -- <br />601 N. Webb Road, Grand Island, Ne. 68803 -4050 <br />23 . IMMEPLrE CAUSE /I�(O (ENT R ONLY jONE CAUSE P *R LW FFOA �.ar it4. ANO KU 1 E,- pge.v.l tlel7wr.n vnM Hvn. �sA w PART <br />DUE TO. OR AS A CONSEOLIENCE OF kXe•..x Meer. .wl n.•.+n- <br />RN <br />DUE TO. OR AS A CONSEOUENCE OF wer•rr trrween onsr a•.1 neax _ ._. <br />(o) <br />PART OTHER SIGNIFICANT CONDITIONS- Cmueoea 0"OL&V b av dealh OY AO1 NMMe PART 0 K FEMALE. WAS THERE A 2a AUTOPSY 25 WAS LAST HFFFRRED TO MEDICAL <br />a PREGNANCY IN THE PAST )MONTHS' wEXAMINE A ()A CONONF H " <br />(Ages IO 541 Yes 0 NO Yea n w No <br />26. 260 DATE OF HAIRY IUb ON Yr, 26c HOUR OF INJURY 280 OE SCRIBE HOW FLIURY OG RRED __.. <br />❑ Acc10ere ❑. 11x0e1eI�1a0 M <br />❑ Siede ❑ Pool 2N OWRY AT WORIt PIACE OF FUMNY_M1X/rle.wm sFee1 NKwy 269 LOCATION STREET DaRFD NO 1,110A IOWN _.— "1At1 __.. <br />❑ "01 -C4, In"s"soOe Y" ❑ - 1:11" On+Mlg JpTNI <br />27a DATEOFOEATH 1W DAY Yr, 28a DATE SWNED iw DAY Y•I 260 tiMF OF DEATH -__ - <br />i <br />November 5, 1997 <br />3 270 DATESIGNED /NAT Der Yli 77c TAFE OF DEATH 26c PRONOUNCEDUEAD �W OaY.Yrl 2110 PRDNI h�Ix.Eri:k AD <br />k � 3:50 AM M <br />M <br />.: 270 t0 er OM d w ouwnle r ar ar Oro dace anO lMe a ar :? 26e On aIe bass d e.amnraon arw a X1.eswOrm n •ml Opn.r nealn .x r ✓•s0 r . <br />cawlr er br Ore am Mace Oro dAl 10 h G 44 U"14 <br />— T-I P, _ <br />29 DID TOBACCO USE C TRI E TO THE DEATNT 3Da HASORGANORTISSUE D04ATIONQEE CONSIDERED, 300 WAS CONSENT GRANTED' <br />X ❑ YES ND ❑ IgelvloWN v ❑ YES WJ <br />31 NAMEANDADORESSOF ERTKIERIPHYSICWe. CORONERSPHY SICIANORCOUNTYATTORNEY, :irp.a A#rI/I <br />X John A Wagoner Jr MD, $00 Alpha Street, Gran <br />32a REGISTRAR - _ I <br />L/ ❑ YESN1, <br />(d Ne 68803 <br />320 DATE FILED BY RF GIST AAR 1W !L. —r.I <br />NOV 121997 <br />