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<br />STATE OF NEBRASKA
<br />•
<br />Li
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS n }
<br />2 019 0 5 6 5 5 ASSISTANT STATE REGISTRAR
<br />RUSSELL FOSLER
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />3/4/2019
<br />LINCOLN, NEBRASKA
<br />11. DECEDENT'S -NAME (First, Middle, Last, Suffix) 12. SEX 1 3. DATE OF DEATH (Mo., Day, Yr.)
<br />I
<br />James William M/ieaert ;vials 1 February 24, 2019
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceasod are filed with thl county court in the county where the decedent resided at the time of death.
<br />4. CITY AND STATE
<br />OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (f.1o., Day, Yr.)
<br />Grand Island,
<br />Nebraska
<br />(Yrs.)
<br />75
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />August 20, 1943
<br />7. SOCIAL SECURITY NUMBER
<br />506-58-9393
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑Inpatient OTHER ❑Nursing Home/LTC ❑Hospice Facility
<br />8b FACILITY -NAME (If not Institution, give street and number)
<br />2319 West Charles Street
<br />0 ER/Outpatient ®Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />i
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />SSa. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />d. STREET AND' NUMBER
<br />2+ 2319 West Charles Street
<br />D.e. APT. NO.
<br />9f. ZIP CODE
<br />63803
<br />9g. INSIDE CITY LIMITS
<br />© YES 0 NO
<br />MARITAL STATUS AT TIME OF DEATI I Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Linda Gail Lewis
<br />l^.. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Wlegert
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Catherine Sass
<br />13. :EVER IN U.S. ' RMED FC?CES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Linda Gail Wieqert
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑Burial 0 Donation
<br />16a, EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />March 1, 2019
<br />® Cremation ❑Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />_.
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />i7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />17b. Zip Code
<br />6.8801
<br />CAUSE OF DEATH i ee instructions and exam. est
<br />ib. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Chronic Obstructive Pulmonary Disease
<br />disease or condition resulting
<br />onset to death
<br />Years
<br />in death)
<br />frC C -E UElV 3
<br />Sequentially list conditions, if <, b)
<br />any, leading to the cause listed
<br />en line a.
<br />-
<br />• , f7 .sec
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(diseaseor injury that initiated
<br />onset to death
<br />Ute events resuhinin death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. ()THE ' SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICA . EXAMINER
<br />CR CORONER CONTACTED?
<br />E YES 0 NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />M
<br />0 Pregnant at time death
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® Ni?
<br />o Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />0 Suicide 0 Could not be determined
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21 d. WERE AUTOPSY F:NDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />YES ❑.NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN ST'.'.'_ ZIP CODE
<br />To Le cunpleted by
<br />MEDICAL CERTIFIER
<br />_ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />z
<br />o g =
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />February 25, 2019
<br />24b. TIME OF DEATt:
<br />Approx. 09:30 AM
<br />23b. DATE SIGNED(Mo., Day, Yr.)23c.
<br />y
<br />TIME OF DEATH
<br />c
<br />i s •• }
<br />E H ). El
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />February 24, 2019
<br />24d. TIME PRONOUNCED DEAD
<br />10:18 AM
<br />3d. To the best
<br />and due
<br />u
<br />of my knowledge, death occurred at the time, date and pace ' w i
<br />to the cause(s) stated. (Signature and Title) g o p
<br />4) s
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />_. Cie time, date and place and due to the cause(s) stated. (Signature and Ttle)
<br />Sarah Hinrichs, Hall Deputy County Attorney
<br />5. DID TO8ACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />.27. NAME, TITLE AND ADDRESS OF CERT:FIER (Type or Print
<br />Sarah Hinrichs, Hall Deputy Count; Attorney, 231
<br />S. Locust, Grand Island, Nebraska, 68801
<br />'r' a REGISTRAR'S SICNATURE,,,+
<br />28b. DATE FILED BY REGISTRAR Mo., Day, Yr.)
<br />March 1, 2019
<br />.lrTe
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