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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES,TI,E RAISED SEAL OF THE NEBRASKA
<br />SYSTEM, IT CERTIFIES THE LOW TO BE A TRUE COPY OF TW
<br />THE NEBRASKA HEALTH OM HUMAN SERVICES SYSTEM, V
<br />THE LEGAL DEPOSITORY FIR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />SEP 2 0 2005
<br />LINCOLN, NEBRASKA
<br />202602189;:
<br />• STATE OF NEBRASKArDEPARTMENT OF HEALTH AND HUMAN SERVICES FINA
<br />CERTIFICATE OF DEATH
<br />09594
<br />1. DECEDENT'S -NAME (First, Middle, Laet, Suffix)
<br />Nathaniel T.4-. Weber
<br />2. SEX
<br />'Male
<br />3. DATE OF DEATH (Mo., Day,Yr.)`
<br />August 27, .,2005
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN C0UMtRT OF BIRTH
<br />t}.
<br />Altenburg, Missouri,:
<br />5e. AGE -Last Birthday
<br />(Yrs.) '
<br />82
<br />6b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day,Yr.)
<br />August 15, 1923
<br />'MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NU)ABERr507-18-7076
<br />$07
<br />ea. PLACE OF DEATH .
<br />HOSPITAL: 0 Inpatient (JILT ❑NursingHome/LTC ❑HospieeFed*ryr
<br />.17.;.7.0y�..7~;,-_,-.
<br />❑ ER/Outpatient at Decedent's Home
<br />0 bat . ❑ Other (1svecn»
<br />- 1lb. FACILITY -NAME (11 net Institution, give siva end number)
<br />F--.•sue.
<br />2612 W. Division t. Q
<br />.
<br />8c. CITY OR TOWN OF DEATH. (Include? -
<br />Grand Island, Nebraska 68803
<br />Bd.000NTY OF DEATH
<br />Hall
<br />ga. RESIDENCE -STATE _
<br />Nebraska
<br />bblAr
<br />Hall
<br />9c.C(TYORTOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2612 W. Division Street --
<br />9e. APT. NO
<br />91. ZIP CODE •
<br />68803
<br />gg. INSIDE CITY LIMITS
<br />W VEs ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH 2 Married Wirier Married
<br />❑ Mauled, but separated ❑Widowed ❑Divorced ❑Unnown
<br />108. NAME OF SPOUSE (First, Middle, Last, Suffix) I1 wife, give maiden name. -
<br />Alice Heider
<br />II. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Herman Weber
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Suzanne Poppitz
<br />t3. EVER IN U.S. ARMED FORCES? Give dates of service I yes.
<br />(Yee, no,orunk.) Yes 2-10-43/9-18-45
<br />14a. INFORMANT -NAME
<br />Alice Weber
<br />14b. RELAT101T8IIIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION ,
<br />Dew.' ❑oonetlon
<br />16a. EMBALMER-SIGIIATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yi, )
<br />August 27, 2005
<br />2 Cremation 0 Entembmenl
<br />0 Remold ' 0 Other (Specify)
<br />18d. CEMETERY, CRIOdATORY OR OTHER LOCATION CITY / TOWN STATE
<br />•
<br />Westlawn Crematory Grand Island, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) A
<br />Livingston'Sondermann F.H. 601 N. Webb Rd. Grand Island, Nebraska"
<br />17b. Zip Code
<br />68803.
<br />+ .
<br />16.' PART 1. E diseases, InM1ee, , .. sop ar P' d . ; klerminatauentestichas earths art I , APpBOX E E.
<br />resdrakNl„Mriet,orventrkdailbrWationwffltoetsho1 theetdbgy.00NOTABBREVk1*E.Enter MO&satelWeo a eHMaseIeeaa ark ) k'
<br />IMMEDIATE CAUSE: ' I asebtNallr - f - • +
<br /><y� eIN' )
<br />NIMEDIAlECAUSE(Flnd (°) \ wiy l {n
<br />V r ss.
<br />d rieiwiercondl6on resulting DUE TO, OR AS A CONSEOUENC6 OF: ;' 1 orraetto death:,; t -• T
<br />In death) 1 '
<br />Ssgasntlslly Net conditimy If (b) ' I
<br />aey,lsed ngtotheceuaepsbd DUE TO, OR AS A CONSEOUENCEOF: 14, -f onset to death -
<br />onllnea , I
<br />Werth. UNDERLYING CAUSE ! ( 1
<br />(disease orInjury that inMeted (c)
<br />I
<br />}i
<br />tb°°""""altkgMdeath) DUE TO, OR AS A CONSEQUENCE OF: 1 i onset to death <
<br />LAST (� r �,, 1 'N a
<br />18. PART It. OTHER SIGNIFICANT CONDITIONS-Condltions contributing to the death but not resulting In the underlying cause glv n In PART L
<br />ii
<br />t g. WAS MEDICAL EXAMMI! i x
<br />tr.
<br />OR CORONER E.:01.
<br />❑ YES
<br />20. IF FEMALE:
<br />0 Not pregnant within pest year
<br />❑ Pregnant at time of death
<br />42 deyeeidesth*
<br />0 Not pregnant, but pregnant within 42
<br />0 Not pregnant, but pregnant 43 days to t year baton death
<br />t I,J.Inkyjiwn M pregnant within the pest year
<br />21a. MAIISR OF DEATH
<br />ti tunt Honpcfde
<br />sN,
<br />0 Accident❑ Pending Investigation.
<br />ONutclde 0 Could not be determindd
<br />,- .. _
<br />.
<br />21b. IF TRANSPORTATION
<br />❑ Ddvsrllo,enbr
<br />O Passenger^+'
<br />INJURY
<br />21c. WAS AN AUTOPSY PERFORMS!?
<br />0 YES
<br />Pedseaien
<br />❑ er (Specify)
<br />2T'd. AUTOPSYFgJgNGSAVAI TO .;,
<br />COMPLETE cAUSEOF Donn
<br />: 0 YES l . NO,-m. ,
<br />t
<br />22a. DATE OF INJURY (Mo., Day, Yr.) ;' , f 22/ITINE OF INJ4.#
<br />22a�PLACE QE IN,lifrit lanS,7pnni,slre pglaTy "11.01IMVI
<br />(aUon '
<br />r+:d"i.,n lime-�,r
<br />n7 n.,., : f,
<br />`•
<br />. '�. Itn -77-7. -'rIf 6 .. •1
<br />Itt"-#1.... 4_' na,.' A.
<br />,T,'x
<br />I
<br />2INJURYAF* WORK?
<br />Zad.
<br />OYES tl NO
<br />22e. DESCRIB e ' e • nR� t '
<br />i a , " V
<br />22!.LOCATIONOFINJURY-STREET&
<br />wlf RYR
<br />. COWN OOb6 t
<br />+
<br />TEOFF(DDEE%ATH(Mo.,,DDay, Yr. . 4
<br />4
<br />?N1a.DATESIGNED (#do Del�Yr)
<br />24bTIMEOFDEATH r
<br />b.DATESIGNED o.,Day, Yr.) •
<br />µ .411 4PDEATH III
<br />2C.PRONOl1N•
<br />CEDDE (Mo.•Day^Wry
<br />$4d f MEAD
<br />. /V M. Ka.1..J arl.il.tll..w' MuaJNw.Nti,
<br />', nth I ,,,•a.I.a
<br />.r nry wr r., .n.vn•rren, rvv.n wrnn-
<br />and due the causes) statbd. (Signat*e
<br />ar .
<br />26.0IDTOBAPAO USE CONTRIBUTE
<br />❑YE
<br />T.NA EAND AKA SS 1FCERTIFIER rPHYSI
<br />T iq Mubi> t. MD 800
<br />REGISTRAR'S SIENA
<br />�7+
<br />OBABLY CI UNK
<br />NAS ORG
<br />0 YES
<br />•
<br />:he Ilme, date and
<br />0TrSuE DONATION BEEN CONSIDERED?'
<br />,
<br />R'BPHYBIctANORCOUNTYgnawer) (iyptorPito
<br />t. •Grand Island;.Webrekeka:".68803
<br />28b. DATE FILED BV EGISTRAR /to:, Day, Yr.)`
<br />to tin ceuse(s)`stat'ed. (6lpiiejtns and
<br />26b.WAS (XINSENT GRA
<br />K.
<br />Applicable If'2(la le NO GI)t& T "_
<br />1
<br />1
<br />
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