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aftit".'11.1811%:r mit WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 7/20/2020 LINCOLN, NEBRASKA 2020.05709 j 'c? .11 414,4, 1' / 4 r14_ SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 19 03116 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death, I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Kathy Kay Weber 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) March 9, 2019 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTI4 Mo., Day, Yr.) Beatrice, Nebraska (Yrs.) 60 MOS. DAYS HOURS MINS. February 22, 1959. 7. SOCIAL SECURITY NUMBER 507-94-0528 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home 0 DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Cairo 9d, STREET AND NUMBER 518 West Egypt 9e. APT. NO. 9f. ZIP CODE 68824 9g. INSIDE CITY LIMITS ® YES 0 NO los. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Frank Weber 11. FATHER'S•NAME (First, Middle, Last, Suffix) DoVIe Brundage 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Peggy O'Neill 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Frank Weber 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION 0 Burial ❑Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) March 11, 2019 El Cremation 0 Entombment ❑Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Horne, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Coda 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- dl , injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: ININ(EDIATECAUSE (Final a) Hypoxic Respiratory Failure disease or condition resulting onset to death Immediate '. in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Metastatic Breast Cancer any, leading to the cause listed onset to death 201 7 online a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury' that initiated onset to death .. the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18.. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Transitioned To Comfort Cares And Passed On Inpatient Hospice 19. WAS MEDICAL EXAMINER OR CORONER' CONTACTED? ❑ YES ®NO 20. IF FEMALE: Not pregnant witltifl::padt year 0 Pregnant at time of death '' 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ] NO ❑ Nat pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death QUnknown If pregnant within the past year Suicide Could not be determined 0 ❑ 0 Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f, LOCATION OF INJURY' STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) March 9, 2019 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) March 11, 2019 23c. TIME OF DEATH 04:25 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To, the best Ginty knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Michael A. Donner, MD 24a. On the basis of examination and/or investigation, in my opinion death deterred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES El NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN ORISSUE BEEN CONSIDERED? ® YES ■ NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES 1 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Michael A. Dormer, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE -T - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 11, 2019