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<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
<br />GATE OF ISSUANCE
<br />2 019 0 7 9 6 STANLEY . COOPER
<br />ASSISTA f STATE REGISTRAR
<br />1/2/2018 DEPARTMENT HEALTH AND
<br />LINCOLN, NEBRASKA HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Magdalene Marie Weber
<br />171
<br />6569
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday 5b. UNDER 1 YEAR
<br />Redwood County, Minnesota
<br />7. SOCIAL SECURITY NUMBER
<br />508-54-4045
<br />(Yrs.)
<br />72
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 22, 2017
<br />8. DATE OF BIRTH (M4., Day, Yr.)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 24, 1945
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />7 DOA
<br />$b. FACILITY -NAME (If not Institution, give street and number)
<br />North Platte Care Centre
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />North Platte 69101
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2900 West E Street
<br />OTHER E Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Lincoln
<br />9b. COUNTY
<br />Lincoln
<br />9c. CITY OR TOWN
<br />North Platte
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />69101
<br />9g. INSIDE CITY LIMITS.
<br />® YES ❑ NO
<br />10a. MARITAL stems AT TIME OF DEATH E Married ❑ Never Married
<br />Q Marred, but separated ❑ Widowed 0 Divorced D Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />August Schulz
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF 0l$POSrON
<br />El Burial 0 Donation
<br />E Cremation 0 Entombment
<br />0 Removat 0 Other (Specify)
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Donald Joseph Weber'
<br />I12. MOTHERS•NAME (First, Middle, Maiden Surname)
<br />Etha Waters
<br />14a. INFORMANT -NAME
<br />Ron Ochsner
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1613. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (MO, Day, Yr)
<br />December 22, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation West
<br />Paxton
<br />STATE
<br />Nebraska
<br />17a. FUNERAL. HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />Odean Colonial Chapel at C and Sycamore. 302 S. Sycamore St.. North Platte. Nebraska
<br />17b. Zip Cade
<br />69101
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART t. Enter the chitin of events- diseases, injuries, or comptiutionethat directly caused the; death. DO NOT enter terminal events such as cardiac arrest,
<br />Mennatory arrest, Of 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) Metastatic Breast Cancer
<br />disease or condition resulting
<br />in death) _ _.._..
<br />'o be completed b.
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />4 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list copditons, if b)
<br />any, eaning to the eattp listed
<br />on Isle a.
<br />Enter the UNDERLYING CAUSE
<br />(dial/Oe# injury that initiated
<br />the iwnta teaua)ig Side/MS 4:
<br />LAS'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset t0 death
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF.FEMALE:
<br />E Not pregnant within past year
<br />0 Pregnant at time of Math
<br />❑ NGt pregnant,: but pregnant within 42 days of Math
<br />❑ Not pregnant, but pregnant 43 days to 1 year before Math
<br />❑ UnklWwnifprsgn•nt within the past year
<br />22a. DATE OF INJURY (Mo, Day, Yr.)
<br />21a. MANNER OF DEATH
<br />E Natural ❑Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could: not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑- Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YES; ENO`
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABI..
<br />TO COMPLETECAUSE OF DEATH?
<br />0 YES ❑' NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />0 YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Decernber 22, 2017
<br />2313, RATE SIGNED (Mo., Day, Yr.)
<br />Dec m er 29 2017
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />02.40 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Janet Elizabeth Bernard, MD
<br />25; DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />4a DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE' DONATION BEEN CONSIDERED?
<br />DYES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Janet Elizabeth Bernard, MD, 500 W Leota St #100, North Platte, Nebraska, 69101
<br />28e.:REGYST
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 2, 2018
<br />
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