|
:%16WJJA'tt s?t699diHiii9ddtx h.:. a rtylei'dw?"!:, 9t
<br />t9dds�?°. .. nrrrmr�
<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 />DATE OF ISSUANCE
<br />9/15/2020
<br />LINCOLN, NEBRASKA
<br />c
<br />d
<br />v
<br />4.
<br />202200927 ASSISTT STATE
<br />DE ARM NT OF HEALTH REGISTRAR
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1.DEGEDENTS-NAME (first, Middle, Last, Suffix)
<br />Donald LeRoy Weavers
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings, Nebraska
<br />T. SOCIAL SECURITY NUMBER
<br />508-54.2591
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (9f not Institution, give street and number)
<br />CHI Health Good Samaritan
<br />Se. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Kearney 6884$
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Adams
<br />77
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />2012070
<br />3. DATE OF DEATH (MO•k DAT, Yr,)
<br />August 31, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr)
<br />December 4, 1942
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Buffalo
<br />❑ Hospice Faculty
<br />9d. STREET AND NUMBER
<br />8498 West Platte River Drive
<br />9e. APT. NO.
<br />Of. ZIP CODE
<br />68832
<br />8¢ INStDE CITY LyonTS'
<br />❑ ites O '
<br />10a. MARITAL STATUSAT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Marcia Thede
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First,
<br />Howard Weavers Twyla Maine
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Marcia Weavers
<br />Middle, Malden Surname)
<br />14b. RELATIONSHIP TO DECEDENTIp'
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Dennis Harrahill
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Rosedale Cemetery
<br />16b. LICENSE NO.
<br />1330
<br />CITY / TOWN
<br />Rosedale
<br />16c. DATE (Mo., Day, Yr.)
<br />September4, 2020
<br />STATE'
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />17b,21p Code
<br />68801
<br />15. PART 1. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<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 />IMMEOIATECAUSE(Final al Acute On Chronic Hypoxic Respiratory Failure
<br />disease or condition restating
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially list conditions, it b) Hip Fracture
<br />any, leading to the cause listed
<br />en line
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter theUNDERLYINGCAUSE c) Generalized Weakness
<br />(disease or Injury that initiated'
<br />the events resulting in death)
<br />LAST
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />onset to death
<br />Days
<br />Onsettoi
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />it PART It. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Coronary Artery Disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within pan year
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnane: within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO ..
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<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 />❑YES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY:::: STREET & NUMBER, APT.NO.
<br />$ g
<br />a
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />August 31, 2020
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 10, 2020
<br />23c. TIME OF DEATH
<br />07:55 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />Lissa A. Woodruff, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP C.
<br />DE
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death °scurried at
<br />the time, data and place and due to the cause(s) stated. (Signature and UN)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO ❑ YES'
<br />NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Lissa A. Woodruff, MD, 10 E 31st St., PO Box 1990, Kearney, Nebraska, 847
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 11, 2020
<br />
|