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200309461
<br />WHEN THIS COPYCARRES TW RAISED SEAL OF THE NEBRASKA HEALTH ANDIA I IAN $ ERVICES
<br />SYSTEM !! CERTFES T14E BELOW TO BE A TRUE COPY OF THE ORIGINA E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL SI A_Mff*,A� C?1Gk:MfICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />DATE OF ISSUANCE
<br />4/29/2003 - - - --
<br />ITSTATE REAR
<br />LINCOLN, NEBRASKA HEALTH .I 41LSERMES"STEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S CE V0 SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH 03 04703
<br />1. DECEDENT -NAME .. FIRST
<br />MIDDLE LAST
<br />24 AUTOPSY
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Marion
<br />Hazel Seberg
<br />EXAMINER OR CORONER?
<br />rn
<br />Aril 11, 2003
<br />4. CITY AND STATE OF BIRTH /a not in U.S.A. name counay/
<br />Yes No
<br />5a. AGE - Last Birthday
<br />UNDER 1
<br />YEAR
<br />°
<br />6. DATE OF BIRTH /Mortar. Day. Year/
<br />Sb. MOS.
<br />'
<br />DAYS
<br />rn
<br />Watertown, Florida
<br />D
<br />Aril 23, 1927
<br />7. SOCIAL SECURTIY NUMBER
<br />Suicide Pending
<br />o -f
<br />fD
<br />267-38-5099
<br />HOSP_ I_TAL
<br />❑ Inpatient - OTHER: ® Nursing Home
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (a rot msafution, give street and number/
<br />::c
<br />nn v
<br />Aril 11, 2003
<br />❑ DOA ❑ Other(Specdvi
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />M
<br />ry
<br />�'
<br />o
<br />M
<br />D N
<br />I Adams
<br />9a. RESIDENCE - STATE
<br />O
<br />�'
<br />\yy
<br />9c. CITY. TOWN OR LOCATION
<br />o
<br />9d.. STREET AND NUMBER /includhg Zip CPdq( 9 0 1
<br />ail
<br />r)
<br />CA
<br />Adams
<br />Hastings
<br />causefs) stated.
<br />W
<br />Yes F3 No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, gtc�
<br />® MARRIED Q WIDOWED 13. NAME OF SPOUSE pl wife. give maiden name)
<br />et °.)ISpe,ite
<br />($peCi ")English /Irislljl
<br />112.
<br />NEVER DIVORCED Dr. John Ra and Seber RlE.
<br />14a. USUAL OCCUPATION /Give kirdof wool* done du" most
<br />❑ YES E�'NO ❑ UNKNOWN
<br />14b. KIND OF BUSINESS INDUSTRY
<br />p
<br />15. EDUCATION (Specify only highest grade completedl
<br />Elementary or Secondary 10 -121 College 11-4 or 5 -1
<br />of working life, even if reared)
<br />Homemaker
<br />Own Home
<br />is 2
<br />1'2 4
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER
<br />o
<br />John E,
<br />Johnson
<br />(17
<br />S 3
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.) (tl yes. give war and dates of services)
<br />F✓
<br />C
<br />Cn
<br />Dr. John Raymond
<br />Seberg Husband
<br />Cn
<br />t--�
<br />Cn
<br />O
<br />200309461
<br />WHEN THIS COPYCARRES TW RAISED SEAL OF THE NEBRASKA HEALTH ANDIA I IAN $ ERVICES
<br />SYSTEM !! CERTFES T14E BELOW TO BE A TRUE COPY OF THE ORIGINA E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL SI A_Mff*,A� C?1Gk:MfICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />DATE OF ISSUANCE
<br />4/29/2003 - - - --
<br />ITSTATE REAR
<br />LINCOLN, NEBRASKA HEALTH .I 41LSERMES"STEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S CE V0 SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH 03 04703
<br />1. DECEDENT -NAME .. FIRST
<br />MIDDLE LAST
<br />24 AUTOPSY
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Marion
<br />Hazel Seberg
<br />EXAMINER OR CORONER?
<br />Female
<br />Aril 11, 2003
<br />4. CITY AND STATE OF BIRTH /a not in U.S.A. name counay/
<br />Yes No
<br />5a. AGE - Last Birthday
<br />UNDER 1
<br />YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mortar. Day. Year/
<br />Sb. MOS.
<br />'
<br />DAYS
<br />5c. HOURS' MINS.
<br />Watertown, Florida
<br />(Yrs.)
<br />75
<br />Aril 23, 1927
<br />7. SOCIAL SECURTIY NUMBER
<br />Suicide Pending
<br />Be. PLACE OF DEATH
<br />261. PLACE OF.I,NJ, URY (M Ij. farm. sbeet. factdry
<br />267-38-5099
<br />HOSP_ I_TAL
<br />❑ Inpatient - OTHER: ® Nursing Home
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (a rot msafution, give street and number/
<br />Perkins Pavilion
<br />�<
<br />Aril 11, 2003
<br />❑ DOA ❑ Other(Specdvi
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />M
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Hastings
<br />28d. PRONOUNCED DEAD /Hour)
<br />V85 13 No ❑
<br />I Adams
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />11:20 AM
<br />9c. CITY. TOWN OR LOCATION
<br />9d.. STREET AND NUMBER /includhg Zip CPdq( 9 0 1
<br />ail
<br />9e. INSIDE CITY LIMITS,
<br />Nebraska
<br />Adams
<br />Hastings
<br />causefs) stated.
<br />1306 S nish T
<br />Yes F3 No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, gtc�
<br />® MARRIED Q WIDOWED 13. NAME OF SPOUSE pl wife. give maiden name)
<br />et °.)ISpe,ite
<br />($peCi ")English /Irislljl
<br />112.
<br />NEVER DIVORCED Dr. John Ra and Seber RlE.
<br />14a. USUAL OCCUPATION /Give kirdof wool* done du" most
<br />❑ YES E�'NO ❑ UNKNOWN
<br />14b. KIND OF BUSINESS INDUSTRY
<br />❑ YES ®
<br />15. EDUCATION (Specify only highest grade completedl
<br />Elementary or Secondary 10 -121 College 11-4 or 5 -1
<br />of working life, even if reared)
<br />Homemaker
<br />Own Home
<br />1'2 4
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />John E,
<br />Johnson
<br />Bessie Morgan
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.) (tl yes. give war and dates of services)
<br />1
<br />No I
<br />Dr. John Raymond
<br />Seberg Husband
<br />190. INFUHMANI MAIUNU AUUncJJ IJ �nCCl vn n.r.v.nv.. �.IlT Vn i�.rn. u, n,c url
<br />1306 S apish Tr Hastings, Nebraska 68901
<br />20. MER GN RE 8 ZLICENO �� 118 9 21a METHOD OF DISPOSITION 21b. DATE - 21 c. CEMETERY OR CREMATORY NAME
<br />® Burial 1:1 Removal Aprf 14,
<br />22a. FUNERAL HOMIN, NAMt 21 d. CEMETERY OR CREMATORY LOCATION CI7V OR TOWN STATE
<br />Livin stop- Butler - Volland F.H. ❑crsmabon 11 Donation
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1225 N Elm Ave., Hastings Nebraska 68901
<br />23. PART IMME TE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR let. (b). AND (c)) - I Interval between onset and death
<br />I
<br />I I
<br />a) r
<br />DUE T , OR A CONSE OF I Interval between onset and death
<br />DUE TO, OORAS A CONSEOUENCE /O/F:: Interval between onset and death
<br />OTHER SIGNIFICANT CONDITIONS - Candhiore corltribuling to the death but not Witted PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages 10-54) Yes No
<br />Yes No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (Mo. Day.
<br />UR OF INJURY
<br />DESCRIBE HOW IN,,JRY OCCURRED
<br />Accident Undetermined
<br />77
<br />126d.
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />261. PLACE OF.I,NJ, URY (M Ij. farm. sbeet. factdry
<br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑❑
<br />Yes NO ❑
<br />olfide Ile aid. SPae�l
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />�<
<br />Aril 11, 2003
<br />M
<br />27b. DAT7SNED / .. Day. Yrl
<br />27c. TIME OF DEATH
<br />2sc. PRONOUNCED DEAD fMo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD /Hour)
<br />Y � }
<br />o
<br />11:20 AM
<br />8�
<br />M
<br />27d. To the best of rh knowledge. death occurred.atth e 11 date and place and due to the
<br />/
<br />2Be. On the basis of examination and,or investigation, in my opinion death occurred at
<br />e
<br />causefs) stated.
<br />a
<br />the time. date and place and due to the cause(s) stated.
<br />'Signature and Tine( ►
<br />(Signature - and Title) b,
<br />29. DID TOBACCO USE CONTRIBUTE M THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DO ATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />N0
<br />❑ YES E�'NO ❑ UNKNOWN
<br />* 'YES ❑ NO
<br />❑ YES ®
<br />J1. NAMt ANU AUUHCJJ Ur I Mri l Ir- 1- TJltilnn, l.vnV . rn,.- Vn ♦ 11.1 n . vn , r „rye v , ""
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