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<br />f, �. ___........ STATE OF NEBRASKA....�l1P1;�t➢3`.;,:'ae2hhrddDa»ARa.: R8461.1fMAPg3sa>��•eevYJ.ttylklSesx=... ,s yygyc..:....rcyr�rhhh4rtll>!i:
<br />. •Yrc:. , v1`x _ .x;'s < . ss,s.�'$t":e '...,r.,'sas : .
<br />•
<br />EN THIS C lsPY A RIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BEL,O)
<br />RE A"' 'RUE COPY OP THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />a�rE< ISSUANCE
<br />8f' 912o24
<br />LINCOLN, NEBRASKA
<br />202405272
<br />SARAH BOHNENKA
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1::.#7ECELtEN'f'S-N#ME::'(F►rst, Middle, Last, Suffix)
<br />:An#lititi • liar :: Weidner
<br />44 CITY`AND:STATt R TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />:indsay;;:Nebraska
<br />T:;SOC{AL SECURITY NUMBER
<br />8b. FACIUTY.NAME (H not Institution, give street and number)
<br />3027 Goldenrod Drive
<br />8c:CITY::ORIOWNN OF DEATH (Include Zip Code)
<br />Grand Island<>SB801
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9d STREET.AND NUMBER
<br />> 3027 Goldenrod Drive
<br />9b. COUNTY
<br />Hall
<br />10a.'MARITALSTATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />} Marred, but separated ❑ Widowed ® Divorced 0 Unknown
<br />>FATl1ER'S441AME;(Firat, Middle, Last, Suffix)
<br />Marcy .' .:; Neldner>
<br />13''Ei/EIt IN V S. ARMED FORCES? Give dates of service if Yes.
<br />{Yes, No, or Unk.) No
<br />18, METHOD;OF o18P,2SITION
<br />Burial
<br />potation
<br />Creiltat)titt Entombment
<br />❑ Ramovat D`other (Spediy)
<br />Sa. AGE - Lief Birtliday
<br />(Yrs.)
<br />77
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />4 PLACE OF DEATH:
<br />HOSPITAL, o Inpatient
<br />❑ ER/Outpatient
<br />❑:DOA
<br />9c. CITY OR TOWN
<br />Grand: Island
<br />HOURS
<br />MINS.
<br />3. DATE to
<br />Au
<br />OTHER ❑ Nursing Home/LID
<br />Decedent's Home
<br />❑ Other (Spey)'
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give no
<br />14a. INFORMANT -NAME
<br />Kelly Lamborn
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12.:MOTHER'S•NAME (First, Middle, Maiden
<br />Iorraine .; Bakowski
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />111;"FUMERAI HOME:NAME AND MAILING ADDRESS (Street, City or Town; State)
<br />AI! Faiths Funera ;;;Home, 2929 S. Locust Street, Grand Island,.Neb• raske
<br />•
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />14. PART I. Enter the chain of events- .diseases, injuries, or complicatlonsehat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory enlist, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ens. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Oral cancer
<br />a Mae
<br />sitibttiliti
<br />Induth)
<br />Sequential* tatcontlkknt, if
<br />any :t!adtns tp2D4 tenet: Hated
<br />oialliw A
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EitieteSei:UNllSKYlt :GAUBIt C)
<br />(lineal► or inigiiinat initiated
<br />thsevenb moulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />it PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing tothe 'death :but not
<br />hypertension'
<br />-`
<br />26,>IF:FEMAt .E.
<br />Akit`p egr entwttif nt 0' 2year
<br />P#1.#0 aE31m u1**
<br />Net prsgntnt, bUiPiVignantwistin 42 days mown
<br />© Not pregnant but pregnant 43 days to 1 year before death
<br />U.pknowtt ifprslptK.M MMln the pest year
<br />OF.tttJui s! No., Day, Yr.)
<br />22d.INJURY AT WORK?
<br />CJYES ;<;❑o
<br />uilin9 in the underlying cause given in PART I.
<br />21a. MANNER OF DEATH .
<br />Natural Q..HomkkN
<br />Accident aliientlirig �n'tstt(itltlort<: '
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE Ofi INJURY At; horn
<br />228+ DESCRIBE HOW INJURY OCCURRED
<br />2Fr':t.00A'fIONOOP INJURRY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Audust13, 2024
<br />23b..DATE':.SIGNED(Mo.,'Day, Yr.) 23c. TIME OF DEATH
<br />>ALEIJ t t5s:.PQ44 , 02:26 AM
<br />7p ii aair Icnowbdgp,'death occurred at the tans, date and place
<br />.....id due to:tli►' cause(a) stated. (Signature and Title)
<br />had Vieth, MD
<br />:)
<br />+;06
<br />TE
<br />TO THE DEATH?
<br />BLY ® UNKNOWN
<br />29b. IF TRANSPORTATION INJURY
<br />pt/vsr/operator
<br />;:
<br />Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />1do.'EiiATE<(MX<k., f
<br />Aud.ttst
<br />21c. WAS
<br />Li yes
<br />dW 21AUN
<br />a, Street, factory, office building,
<br />STATE
<br />24s. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />!6n the beds of examination and/or Invsttigetbn,Nr
<br />`s Sfa:thne, date and place and due to the causes)
<br />2&;tf►, TO$A,> , ;US.:EGONTtU 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />fEE €; > 'NO ..: PROBA ❑ YES El NO
<br />NAlm MILS AND ADDRt $S OF CERTIFIER (Type or Print
<br />Chad Math,' MO 2116 WP'aidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />:24a. REGISTRAR'S'SIGNAt
<br />.84
<br />26b. WAS CC
<br />Not Applicable If 26e
<br />28b. DATE
<br />August
<br />
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