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200107461 Rev. 11/97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND ${,JMAN S®tVtCBS FINANCE AND SUPPORT VITAL STATL CERTIFICATE OF DEATH N C O O C 7 0 U O d E N X m U F- Z E W 0 C w� 0 � L LL o Oa W m G N 7 a Z U. M FOR VITAL STATISTICS USE ONLY Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part II NSC ...................................................................................:.................................... ............................... Work....................................................................................................................... ............................... UC ............................................................................................................................ ............................... 0 Printed with say Ink on tecycled paper e I hereby certify this to be a true and correct copy of the original fil d with the State of Nebraska by _ Signed in my his12_ d i l44 00 -7- Notary Public TMV........................... .. Census Tract No. GENERAL NOTARY -State of, Nebraska .. MY Comm, Exp t. 1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH lWowA. Day. Yeast John Peter Weinert Male July 13, 2000 4, CITY AND STATE OF BIRTH land in US.A.. name country) Sa. AGE • Last Birthday UNDER 1 YEAR UNDER 1 DAY & DATE OF BIRTH pManR ay. YW MOs. I DAYS Sc.HOURS s. St. Paul, Nebraska (Yrs.l 83 5b December 5, 1916 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH , 508 -03 -2466 HOSPITAL [3 [3 ,ad., OTHER: ❑ Nte"Poilix ❑ ER Oupahm PA$k*k. 8b. FACILITY - Nsma (a not osfMAM giw street and number/ St. Francis Medical Center ❑ DOA ❑ Dow (w"I Bc. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8a. COUNTY OF DEATH Grand Island Ya I Hall ga. RESIDENCE -STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (hcit"I"Z4 Cody 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 1224 St. Paul Rd. 68801 Yes ® No ❑ 10. RACE . (e.g., While. Black. American Indian. 11. ANCESTRY )saga. Italian. Mexican, German, ski 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE (M talks ownkaiten nwtrry w IISpecdy) White (SpecdYl American I NEVER DIVORCED MARRIED 1 Isabel Dorszynski 14a. USUAL OCCUPATION /One kind.( work dons ale/np most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION ISpee dwpbpl4b,ewnitn9krBd) Job Superintendent Building Construction (0•i� ' CaYga lt•4 or S•I ., Elam" ra e 18. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME George A. Weinert Bessie Vincik 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 198. INFORMANT - NAME (Yes, no. or urk.) IN yes, give war and dates of so iceal No - - - - - -- Isabel Weinert 19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) ' 1224 St. Paul Rd., Grand Island, NE 68801 20.E L - SIGNA E NO p 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY - NAME ALENISE lWestlawn ® Banat ❑ Removal July 19, 2000 Memorial Park 22a. FUNERAL NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston - Sondermann F.H. ❑Or" ❑" Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR to), ft AND (aI _ X kaNVal Oalrr.an ~am atath XPART Cardiorespiratory arrest 6 �/p q 4'5 181 I , DUE TO. OR AS A CONSEQUENCE OF I ktfarval balwaan ~ end team ,coronary artery disease I WE TO, OR AS A CONSEOUENCE OF I k0" balw..n or" and death 1 I Iq I OTHER SIGNIFICANT CONDITIONS - Condsons cattrMtaing to are death but not related PART II IF FEMALE. WAS THERE A 24 AUTOPSY { WAS CASE REFERRED TO MEDICAL PART PREGNANCY lineal In dependent diabetes Id THE PAST 3 MONTHS? Ir �^ EXAMINER OR CORONER'+ (Ages 10.541 YM No yes Nb Y.. No 28a. 20b. DATE OF INJURY (W., Day. Yr.) 28c. HOUR OF INJURY DESCRIBE HOW INJURY OCCURRED Accident � Undetermined M 126d. - Sm." � Pending 28e. INJURY AT WORK 281. PLA E OFD U Y ho . farm, West factory bu9d Speceyl 26g. LOCATION STREET OR R.F.D. HO. CRY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ (!U Office 27s. DATE OF DEATH 11111.. Day. Yr.) 28a. DATE SIGNED (Ab.. Day. Yr.l 29b. TIME OF DEATH Ar a� July 13 200 a M 27b. DATE SIGNED (Ado.. Day. Yr..) TIME OF DEATH 26c. PRONOUNCED DEAD (Ada. DW Yr.) 28Q PRONOUNCED OEM O ty k X Jul 18 2 M s M 2P. To dw beat of my krlowladge. de red me. dab and piece due k Iw 289. On IM basis d examineeon.ndrp kww agal , in my ophow death, occur..( a1 • R j� carwMsl atatsd. „.A cY b M Im., Ile and place and ds. b 9r. eawa(q aMYQ and Tills �J .M Too 29, DID TOBACCO USE CONTPoB TO E 30. HAS ORGAN OR TISSUE DONATION BEE SIDERED? 30.b WAS CONSENT GRANTED? ❑ 'GS ND ❑ UNKNOWN 1:1 YES NO ❑ YES NO 31 U&A AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (T a XWilliam J. Lawton, M.D. 2444 West Faidley Ave. Grand Islandt NE 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR ft. Day. Vry FOR VITAL STATISTICS USE ONLY Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part II NSC ...................................................................................:.................................... ............................... Work....................................................................................................................... ............................... UC ............................................................................................................................ ............................... 0 Printed with say Ink on tecycled paper e I hereby certify this to be a true and correct copy of the original fil d with the State of Nebraska by _ Signed in my his12_ d i l44 00 -7- Notary Public TMV........................... .. Census Tract No. GENERAL NOTARY -State of, Nebraska .. MY Comm, Exp t.