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. "tR <br />WHEN THIS COPYCARRES TFE RAISED SEAL OF THE NEBRASKA HEALTH AND tWAM SERVICES <br />SYSTEM, !! CERTFES THE BELOW TO BE A TRUE COPY OF THE OR/ FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL 8 WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ <br />DATE OF ISSUANCE 200409901 10/28/2003 <br />=PER <br />RMSTRAR <br />LINCOLN, NEBRASKA HEALTI#A SSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN V TAN E AND SUPPORT <br />VITAL sTATrsTics=: 3 10905 <br />CERTIFICATE OF DEATH <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />DATE OF DEATH ]Maim. Day. Year) <br />Mar aret Bilb Weiler <br />Female <br />43. <br />Se tember 26, 2003 <br />4. CRY AND STATE OF BIRTH 11not in US.A.. name country] <br />Sa. AGE • Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /North. Day. Year) <br />S <br />5<. HOURS' MIN <br />Fairbur Nebraska <br />(Yrs.) <br />87 <br />June 26, 1916 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />505 -12 -2948 - <br />HOSP_RAL: ❑ Inpatient OTHER: © Nursing Home <br />❑ ER Outpatient ❑ Residence <br />Bb. FACILITY -Name (l/ror inselulion, give sites( and number] <br />Tiffany Square Care Center <br />❑ DOA ❑ Other(Spewtv) <br />Sc. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CfTV LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yo <br />Hall <br />9a. RESIDENCE- STATE <br />_ <br />96. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including, Zrp Code) <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />2820 W. Koeni 68803 <br />Y83EI"d ❑ <br />10. RACE - (e.g., White. Black. American Indian, <br />f 1. ANCESTRY le.g.. Malian. Mexican- German, etc] <br />12- FX-] MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE (N wile. give maiden name) <br />etcl(50eddY) White <br />k.nr")lish /American <br />NEVER DIVORCED <br />George W. Weiler <br />14a. USUAL OCCUPATION /Give kind of work cone riving most <br />14b. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specity only highest grade completed( <br />Elementary Secondary 10 -121 5.1 <br />of work life, even it reared] <br />. Homemaker <br />Domestic <br />V <br />4 Years <br />16. FATHER -NAME FIRST MIDDLE UST <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />William Bilb y <br />Jesse Wright <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />(Yes. no. or unk.) (e yes. give war and Antes of serAces) <br />No -- - - - - -- <br />Sall W. Browne <br />IUD. INFUHMAN 1 MATUNU AUUHt55 151 Mtt 1 UM K .U. r ., tii l T UM n U N. J 1 A I C xarI <br />7734 44th St. N., Oakdale, Minnesota 55128 <br />20. EMBALMER - SIGNATURE 6 LICENSE NO. - - 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME <br />Not Embalmed ❑ Burial ❑ Removal Sept. 26 2003 Westlawn Cremator <br />22a FUNERAL HOME - NAME 210. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livin stop- Sondermann F.H. ®Cremation 1:1 Donator, Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F,Q. NO.. CITY OR TONM, STATE. ZIP) <br />601 N. Webb Road, Grand Island Nebraska 68803 -4050 <br />23. PART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). Ile). AND (c)l 1 Interval between onset and death <br />w, a 1_ I <br />(a) ,,Oil i_ l.^ n.Lf' V 4T`-C. T�i� IX OL 4 %rJ <br />DUE 70, OR AS A CONSEQUENCE OF - - <br />Interval between onset and death <br />I <br />1 <br />Ib1 <br />DUE TO.OR A A CONSEQUENCE aF: I Interval between onset and death <br />S <br />a1 <br />I <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related P <br />PART PREGNANCY <br />a 1 f T 1 <br />II be 1 T t '�A 1 T A V <br />V <br />ART III IF FEMALE. WAS THERE A 124 <br />IN THE PAST 3 MONTHS? <br />(Ages 10 -541 Yes No <br />AUTOPSY <br />Y Z es No <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />l Yes No <br />26a. <br />26b.. DA1TE OF INJURY (Ma. Day. Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJJRY OCCURRED <br />Accident Undetermined <br />M <br />Suicide F Pending <br />Homicide Investigation <br />26e. INJURY AT WORK <br />yes ❑ No ❑ <br />26f. PJ•ACE 1;: NNJUU (At hlxp� , farm. street. factory <br />omce Wrddl SP�rT <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />27a. DATE OF DEATH (Mo.. Day. Yr.) - <br />28a. DATE SIGNED (Mo.. Day. Yr.) <br />28b. TIME OF DEATH <br />y <br />° <br />E�yg�S < J <br />° <br />~ b <br />M <br />27b. DATE SIGNEDI (Ma.. Day. Yr.) <br />27c. TIME OF DEATH <br />�''� <br />28c. PRONOUNCED DEAD (Mo.. Day. Yr.) <br />28d. PRONOUNCED DEAD (Four) <br />27d. To the best of my k <br />�causels) stated. <br />ge. death occurred at the li . datsrend place and due to the <br />28e. On the basis of examination and,or investigation, in my opinion death occurred at <br />the time, date and place and due to the cause(s) stated. <br />iISi nature and Title <br />ISi nature and Title ► <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />3WHAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />WAS CONSENT GRANTED? <br />11 YES 1-1 NO ® UNKNOWN <br />1:1 YES ® NO <br />T30 <br />❑ YES ® NO <br />31. NAME AND ADDRESS OF CEHTIFIEH (PHYSICIAN, CUHUNEH 5 PHY5K:NN UH UUUN I Y A I I UHN t: Y) I1 6 <br />1t�if'i^ 729 N. Cuvter, Grand Island NE 68803 <br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) <br />SEP29MO <br />