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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF 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 />DATE! OP ISSUANCE
<br />8/12/2025'
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (Find, Middle, Last, Suffix)
<br />Denton ;I Weichman
<br />202605889
<br />•
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH /
<br />SARAH BOHNENKAMP T
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Stuart,. Nebraska
<br />T. SOCIAL SECURITY UMBER
<br />506-66-Z-6824
<br />8b. FACILITY -NAME (If not Institution, give street and numbed
<br />CHI Health St. Francis
<br />6e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCESTATE
<br />Nebraska
<br />0d: STREET AND NUMBER
<br />\ 415 Baldwin Ct,
<br />9b.000NTY
<br />Hall
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />NO$PITAL. ❑ Inpatient
<br />® ER/Ou patient
<br />❑ DOA:
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH ((MSo., Qay, Yes)::::;
<br />August 4, 202
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 5,1947;>
<br />OTHER 0 Nursing Home/LTC ❑.,►iospice Facility
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />»d INSrDE Ol'OfLIM)TS :
<br />f . Ye8
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Manled_.10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />❑ Married, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle,
<br />Francis F Weichman
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or Unk.) No
<br />T5. METHOD OFDISPOSITION
<br />®.Burial: ❑ Donation
<br />❑ Crsmation<W Entombment
<br />❑ Removal ❑ Other (Specify)
<br />Last, Suffix)
<br />Ann Brayton
<br />It. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Grar`e C :Kaup
<br />14a. INFORMANT -NAME
<br />Ann Weichman
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />James J. Hoch
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Ainsworth Cemetery
<br />1Ta. FUNERAL HOME NAMEAND MA LING ADDRESS (Street, City or Town, State)
<br />Hoch Funeral.Home,• Inc., 1320 East 4th, Ainsworth, Nebraska
<br />.16b. LICENSE NO.
<br />1105
<br />CITY / TOWN
<br />Ainsworth
<br />CAUSE OF DEAH (See instructions and examples)
<br />IL PART I. Enter the chain of events- 41ssgses, Injuries, or complications -that directly caused he death. DO NOT Ishtar terminal events such is cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without shoving the etiology. DO NQT ABBREVIATE. Enter only oho cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE cause (Final.: a) HYPDXIA
<br />disease er condition resulting .. .
<br />In death)
<br />Sequentially list conditions, if
<br />any, Ieadtfle to the cause listed
<br />on Mite'
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that Initiated
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)BRAIN HERNIATION
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)SUBARACHNOID HEMORRHAGE
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo, Dav r.)
<br />1105
<br />STATE .,
<br />Nebraska
<br />17b.tIpCoda .:
<br />69210
<br />APPROXIMATE INTERVAL
<br />onset tod4ath.
<br />Hours
<br />onset to deafly
<br />Hours
<br />onset to death
<br />Hours •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />it PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but;not ref lung in
<br />e underlying cause given in PART I.
<br />onset toath
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20, IF FEMALE:
<br />Not pregnant within pert year
<br />D Pregnant fit time Of &fifth
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown if pregnant the past year
<br />. DATE OFINJURY.(Mo.,Day, Yr.)
<br />21a. MANNER OF. DEATH
<br />Natural ❑ Ftpmlalde .
<br />0 Accident 0 Pinging lnveatipatlpn
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At ho
<br />21b. IF TRANSPORTATION INJURY
<br />• ❑ Dtiverloperator
<br />❑::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 />❑TES ❑NO
<br />'faith, street, factory, office building, construction site, etc (Specify)
<br />22d. INJURY AT WORK?
<br />CI YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />14f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />1.4
<br />a
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 4, 2025
<br />23b,DATE SIGNED (Mo., Day, Yr.)
<br />August 11, 2025
<br />23c. TIME OF DEATH
<br />10:15 PM
<br />•23d, To the beat ofmy::knowledge, death occurred at the time, date and place
<br />and duo to the;cause(s) stated. (Signature and Tile)
<br />Anthony F. Cook, MD
<br />2&:DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ;..® NO Q PROBABLY 0 UNKNOWN
<br />27. NAME, Me AND ADDRESS OF CERTIFIER (Type or Print
<br />Anthony F. COok, MD, 2620 W Faidley Ave, Grand Island,
<br />28e. REGISTRAR'S SIGNATURE
<br />BII L..� ?
<br />GAN 0
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24C. PRONOUNCED DEAD (Mo.,
<br />24b. TIME OF DEATH
<br />Day, Yr.) 24d. TIME PRONOUNCED DEAR
<br />24s 'On the bank of examination and/or investigation, in my opinion death ocstmtid at
<br />•te time, Elate and place and due to the cause(s) stated. (Signature and tee)
<br />SSUE DONATION
<br />•:fib
<br />Nebraska, 68803
<br />EN CONSIDERg?
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO [] vas
<br />NQ;:;::'
<br />26b. DATE FILED BY REGISTRAR (MD , Day, Yr.)
<br />August 11, 2025
<br />26a. HAS Q
<br />® YES
<br />
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