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A � \
<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERWCES
<br />SYSTEM IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD_ONFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERWCES SYSTEM, WTAL STATISTICS-MCTIO iVHP4 /S
<br />THE LEGAL DEPOSITORY FOR WTAL RECORDS
<br />DATE OF ISSUANCE
<br />3 � � s COOPEI€_
<br />3/11/2004 2®04065 �
<br />AYN_ _
<br />ASSIVANT A�0�S TAAK__
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SEIMAASSSSSSS STM--
<br />2 O �gfB QF� DEPARTMENT OFD HEALTH N HUMAN SERVXESfBd�ICE'ANDSFJPPoRT STATISTICS
<br />�J CERTIFICATE OF DEATH 04 02673
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />M
<br />z
<br />M
<br />D
<br />4. CITY AND STATE OF BIRTH /Knot in USA.. name country)
<br />Sa AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />�
<br />(Yrs -I 57 5b.
<br />INovember 8 1946
<br />MOS. DAYS
<br />So. HOURS' MINS.
<br />7. SOCIAL SECURTIY NUMBER
<br />cn
<br />512-50-5693
<br />HOSPITAL: Inpatient OTHER: ❑ Nursing Home
<br />El ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (Hnot institution, give street and number)
<br />1
<br />DOA ❑ Other fSpec,fvt
<br />9e. CI Y. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMBS
<br />Be, COUNTY OF DEATH
<br />Lincoln
<br />z
<br />Lancaster
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />s.
<br />9e. INSIDE CITY LIMITS
<br />p
<br />t�D
<br />Grand Island
<br />=
<br />M
<br />n
<br />D
<br />V
<br />11. ANCESTRY (e.g., Italian. Mexican, German, etc) -
<br />12. © MARRIED ❑WIDOWED
<br />13. NAME OF SPOUSE fit wife, give maiden name)
<br />,
<br />ISpecAy( American
<br />o -- +
<br />z -�+
<br />N
<br />CL
<br />\
<br />1 S. EDUCATION (Specify only highest grade completed)
<br />of working life, even if retired)
<br />Dis atcher
<br />Truckin
<br />Elementary or Secondary f0 -12) College 11 -4 or 5-1
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Albert Weber
<br />F. CochPnnur
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. no. or unk.) (if yes. give war and dates of servicesl
<br />Yes 5/3/68- /24/ 7
<br />Rebecca R. Wphpr
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />4011 Mason Avenue Grand Island. Nebraska
<br />20. EMBALME - SIGNATURE 8 LICEN E NO.
<br />21 a. METHOD OF DISPOSITION
<br />21 b. DATE
<br />MET ERY OR CREMATORY NAME
<br />® Burial ❑ Removal
<br />7Su
<br />P O E - NAM
<br />d A M e r i c a First Call
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STAT
<br />@ I
<br />❑ Cremation ❑ Donation
<br />Hprinqtnn Kansas
<br />EA R 11 E A (S T R..D. NO.. 09 N. STATE, ZIP)
<br />4425 South 24th Street, Omaha, Nebraska 68107 Rro
<br />Sri nntnn
<br />V- n 449-3038
<br />CE � I Interval between onset and death
<br />23. IMMEDIATE (EN TER ONL 0 AF50#la5Ib1, ANA,?
<br />PART
<br />Respiratory arrest
<br />(al I
<br />r DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />Atherosclerotic heart disease
<br />(b)
<br />DUE TO. OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />Chronic obstructive pulmonary disease
<br />c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />11 Hypoxic encephalopathy
<br />O
<br />EXAMINER OR CORONER'S
<br />(Ages
<br />10 -54) Yes No
<br />Yes No
<br />Ves No
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN,,JRY OCCURRED
<br />Accident Undetermined
<br />C7)
<br />CD
<br />M
<br />Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />26f. office EuOF IN JURY -(SAo , farm, street. factory
<br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />cn
<br />�
<br />27a. DATE OF DEATH [Mo., Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. YrJ
<br />281:r . TIME OF DEATH
<br />3/2/04
<br />=�
<br />C
<br />C
<br />3 v
<br />M
<br />N-i
<br />$ Q T
<br />276. DATE SIGNED /MO. Day. Yr.)
<br />27c. TIME OF DEATH
<br />N
<br />co
<br />N
<br />3/8/04
<br />8:08 p.m.s�a
<br />M
<br />M
<br />g F
<br />211.1.
<br />27d. To the best of my knowledge. death curretl at the ime, date and place and due to the
<br />28e. On the basis of examination and, or investigation, in my opinion death occurred at
<br />to
<br />causelsl stated.
<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERWCES
<br />SYSTEM IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD_ONFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERWCES SYSTEM, WTAL STATISTICS-MCTIO iVHP4 /S
<br />THE LEGAL DEPOSITORY FOR WTAL RECORDS
<br />DATE OF ISSUANCE
<br />3 � � s COOPEI€_
<br />3/11/2004 2®04065 �
<br />AYN_ _
<br />ASSIVANT A�0�S TAAK__
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SEIMAASSSSSSS STM--
<br />2 O �gfB QF� DEPARTMENT OFD HEALTH N HUMAN SERVXESfBd�ICE'ANDSFJPPoRT STATISTICS
<br />�J CERTIFICATE OF DEATH 04 02673
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Kenneth Earl Weber
<br />male
<br />March 2, 2004
<br />4. CITY AND STATE OF BIRTH /Knot in USA.. name country)
<br />Sa AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />W i c h i t a, Kansas
<br />(Yrs -I 57 5b.
<br />INovember 8 1946
<br />MOS. DAYS
<br />So. HOURS' MINS.
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />512-50-5693
<br />HOSPITAL: Inpatient OTHER: ❑ Nursing Home
<br />El ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (Hnot institution, give street and number)
<br />1
<br />DOA ❑ Other fSpec,fvt
<br />9e. CI Y. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMBS
<br />Be, COUNTY OF DEATH
<br />Lincoln
<br />Yea ® Nd ❑
<br />Lancaster
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. S /Including Zip Codel
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />411 ason Ave.6880
<br />YeaO No
<br />10. RACE - (e.g., While. Black, American Indian,
<br />11. ANCESTRY (e.g., Italian. Mexican, German, etc) -
<br />12. © MARRIED ❑WIDOWED
<br />13. NAME OF SPOUSE fit wife, give maiden name)
<br />etc.) (Specify) W h i t e
<br />1.
<br />ISpecAy( American
<br />NEVER DIVORCED
<br />I
<br />Rebecca Manchester
<br />14a. USUAL OCCUPATION (Give kind of work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />1 S. EDUCATION (Specify only highest grade completed)
<br />of working life, even if retired)
<br />Dis atcher
<br />Truckin
<br />Elementary or Secondary f0 -12) College 11 -4 or 5-1
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Albert Weber
<br />F. CochPnnur
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. no. or unk.) (if yes. give war and dates of servicesl
<br />Yes 5/3/68- /24/ 7
<br />Rebecca R. Wphpr
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />4011 Mason Avenue Grand Island. Nebraska
<br />20. EMBALME - SIGNATURE 8 LICEN E NO.
<br />21 a. METHOD OF DISPOSITION
<br />21 b. DATE
<br />MET ERY OR CREMATORY NAME
<br />® Burial ❑ Removal
<br />7Su
<br />P O E - NAM
<br />d A M e r i c a First Call
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STAT
<br />@ I
<br />❑ Cremation ❑ Donation
<br />Hprinqtnn Kansas
<br />EA R 11 E A (S T R..D. NO.. 09 N. STATE, ZIP)
<br />4425 South 24th Street, Omaha, Nebraska 68107 Rro
<br />Sri nntnn
<br />V- n 449-3038
<br />CE � I Interval between onset and death
<br />23. IMMEDIATE (EN TER ONL 0 AF50#la5Ib1, ANA,?
<br />PART
<br />Respiratory arrest
<br />(al I
<br />r DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />Atherosclerotic heart disease
<br />(b)
<br />DUE TO. OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />Chronic obstructive pulmonary disease
<br />c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />11 Hypoxic encephalopathy
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'S
<br />(Ages
<br />10 -54) Yes No
<br />Yes No
<br />Ves No
<br />26a.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN,,JRY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />26f. office EuOF IN JURY -(SAo , farm, street. factory
<br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes 1:1 No ❑
<br />27a. DATE OF DEATH [Mo., Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. YrJ
<br />281:r . TIME OF DEATH
<br />3/2/04
<br />=�
<br />3 v
<br />M
<br />N-i
<br />$ Q T
<br />276. DATE SIGNED /MO. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c, PRONOUNCED DEAD /Mo. Day, Yr.)
<br />28d. PRONOUNCED DEAD /HOUrI
<br />0
<br />3/8/04
<br />8:08 p.m.s�a
<br />M
<br />M
<br />g F
<br />211.1.
<br />27d. To the best of my knowledge. death curretl at the ime, date and place and due to the
<br />28e. On the basis of examination and, or investigation, in my opinion death occurred at
<br />- ° 2 °
<br />causelsl stated.
<br />the time, date and place and due to the cause(s) stated.
<br />1Slgnature and Title) No
<br />(Signature and Title ►
<br />29. DID TOBACCO USE CONTRIBUTE T HE 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />YES ❑ NO UNKNOWN
<br />❑ YES ® NO
<br />❑ YES ® NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />George J. Wolcott, M. D., P.C. - P. O. Box 6937, Lincoln, NE 68506 -0937
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr)
<br />MAR 1 0 2004
<br />
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