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<br />WHEN TINS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN: SERVICES
<br />SYSTEM, IT CERTWES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORD ON FILEWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SIECTKNIt-WHlGFLB
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. "-
<br />DATE OF ISSUANCE
<br />200201067
<br />�R -=
<br />DEC 2 6 2001 ASSISTANT.SFATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMANTEROCES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FRIANCBA�RF
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<br />1. DECEDENT -NAME FIRST .MIDDLE UST
<br />2. SEX
<br />J. DATE OF DEATH beensh Day Yaal
<br />Esther NMI Wegenast
<br />Female'
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<br /><. CITY AND STATE OF BIRTH IHndnUSA. Mamacdmey)
<br />5a AGE 4L BiAbpay I
<br />UNDER YEAR
<br />UNDER 1 DAY
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<br />6: DATE OF BIRTH braO. Day, y0i
<br />MGS wYS
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<br />August 23, 1928
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<br />As PLACE OF DEATH
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<br />Home: 2507 W. Charles
<br />❑ GOA ❑ O""tsix '
<br />&- CITY. TOWN OR LOCATION OF DEATH
<br />M. INSIDE CITY LIMITS
<br />M. COUNTY OF DEATH
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<br />Yea ® No ❑
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<br />9a RESIDENCE - STATE
<br />R: CITY. TOWN OR LOCATION
<br />BE. STREETANDNUM06R fVEAXVplp CWal
<br />41M1SIDE CITY LIMITS
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<br />Hall
<br />Grand Island
<br />2507 W. Charles 68803
<br />Yet ® NO ❑
<br />IO RACE- IS g. WnAB. Block Amencan Irian
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<br />a4 tsdannl White
<br />Isge "nI Russian /German
<br />L }NEVER DIVORCED
<br />MAP E-1
<br />Clarence Wegenast
<br />1 aft. USUALOCCUPATION lGw kvNd wwk Oa'a Wnag mast 14b
<br />KIND OF BUSINESS INDUSTRY
<br />16. EDUCATION SMCin ally llgMM grMe ca pki
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<br />Licensed Practical Nurse
<br />Nursing1L
<br />3
<br />16. FATHER NAME FIRST MIDDLE LAST 11
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George Dockter
<br />Martha Ehrman
<br />1B. WAS DECEASED EVER IN U.S- ARMED FORCES?
<br />t% INFORMANT NAME
<br />(Yea. W. a Y Y.) III yes. awe wa aM date, d MIYKM
<br />No
<br />Clarence Wegenast
<br />1% INFORMANT MAIUNIADDRESS ISTREETORRFO NO..CITYORTOWN. STATE ZIP)
<br />2507 W. Charles, Grand Island, NE. 68803
<br />20. EMBALMER - SIGNAT &LICE SE NO.
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<br />21a METHOD OFO EPOSITION
<br />211. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
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<br />®Bea ❑R.moval
<br />June 14, 2001
<br />Glenvil Cemetery
<br />21a FUNERAL HOME -NAM
<br />CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Lramapn ❑Donald,
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<br />220 FUNERAL HOME ADDRESS (STREET OR R F. D. NO. CITY OR TOWN STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE
<br />ONLY PER ial.Io AND Ul I Interval behaftn�onaamm�ano ni
<br />PARTl
<br />//+ )(ENTER /OON'ECCAUSE (LINE �FOR
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<br />DUE TO OR AS A CONSEQUENCE OF Mbrvel belaaen eras aM Seam
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<br />OTHER SIGNIFICANT, - Cendi imecoeibNing So INS di but no reland PART
<br />III IF FEMALE WAS TMEREA 2<
<br />AUTOPSY 25. WAS LASE REFERRED TO MEDICAL
<br />(CONDITIONS
<br />PART V ✓K... PREGNANCY
<br />IN THE PASTJMONTH9
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<br />2M. DESCRIBEHOWINJORYOCOURRED
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<br />26g. LOCATION STREET OR RFD. NO. CITY OR TOWN STATE
<br />0 He.." Imndi,st.
<br />YB, ❑ NO 1:1
<br />>4Med
<br />3
<br />26a. DATE SIGNED 1M0 Day Ycl
<br />2W TIME OF DEATH
<br />0
<br />is
<br />,S
<br />271 DATE SIGNED (MO(..�MyN;
<br />27c TIME
<br />28c PRONOUNCED DEAD (Me My. Yr.l
<br />281 PRONOUNCED DEAD (Imi
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<br />29 . DID TOBACCO USE CONTRIBUTE TO THE MAIN? a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED+
<br />30.b WAS CONSENT GRANTEDO
<br />❑ YES 9 NO ❑ UNKNOWN ❑ YES ® NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY, lTyppPriml
<br />Richard Fruehling M.D. 2116 W. Faidley, Grand Island,NE. 68803
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<br />321. DATE FILED BY REGISTRAR (Me pay Yq
<br />WHEN TINS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN: SERVICES
<br />SYSTEM, IT CERTWES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORD ON FILEWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SIECTKNIt-WHlGFLB
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. "-
<br />DATE OF ISSUANCE
<br />200201067
<br />�R -=
<br />DEC 2 6 2001 ASSISTANT.SFATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMANTEROCES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FRIANCBA�RF
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<br />CERTIFICATE OF DEATH - _=
<br />1. DECEDENT -NAME FIRST .MIDDLE UST
<br />2. SEX
<br />J. DATE OF DEATH beensh Day Yaal
<br />Esther NMI Wegenast
<br />Female'
<br />June 9, 2001
<br /><. CITY AND STATE OF BIRTH IHndnUSA. Mamacdmey)
<br />5a AGE 4L BiAbpay I
<br />UNDER YEAR
<br />UNDER 1 DAY
<br />/M
<br />6: DATE OF BIRTH braO. Day, y0i
<br />MGS wYS
<br />Sc HOURS MINI
<br />IYM'J72 51
<br />Kenel, South Dakota
<br />August 23, 1928
<br />7. SOCIAL SECURTIY NUMBER
<br />As PLACE OF DEATH
<br />503-24 -5445
<br />HOSPITAL Imeasaft OTHER: ❑ Norana Home
<br />❑ ER OU1ry0an1 ® RaaMence
<br />6b. FACILITY. Name (". ondooson, pw Nreel eM numbed
<br />Home: 2507 W. Charles
<br />❑ GOA ❑ O""tsix '
<br />&- CITY. TOWN OR LOCATION OF DEATH
<br />M. INSIDE CITY LIMITS
<br />M. COUNTY OF DEATH
<br />Grand Island
<br />Yea ® No ❑
<br />Hall
<br />9a RESIDENCE - STATE
<br />96 COUNTY
<br />R: CITY. TOWN OR LOCATION
<br />BE. STREETANDNUM06R fVEAXVplp CWal
<br />41M1SIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2507 W. Charles 68803
<br />Yet ® NO ❑
<br />IO RACE- IS g. WnAB. Block Amencan Irian
<br />11. ANCESTRY to Italian, Mexican. Daman. MCI
<br />12. r[, MARRIED ❑WIDOWED
<br />13. NAME OF SPOUSE IM web IOM me~ name)
<br />a4 tsdannl White
<br />Isge "nI Russian /German
<br />L }NEVER DIVORCED
<br />MAP E-1
<br />Clarence Wegenast
<br />1 aft. USUALOCCUPATION lGw kvNd wwk Oa'a Wnag mast 14b
<br />KIND OF BUSINESS INDUSTRY
<br />16. EDUCATION SMCin ally llgMM grMe ca pki
<br />Ebmenlary Qr Sacon0ary 10 -t21 �Ldlege 11-4 of S-I
<br />d wwama Me. evennrehredl
<br />Licensed Practical Nurse
<br />Nursing1L
<br />3
<br />16. FATHER NAME FIRST MIDDLE LAST 11
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George Dockter
<br />Martha Ehrman
<br />1B. WAS DECEASED EVER IN U.S- ARMED FORCES?
<br />t% INFORMANT NAME
<br />(Yea. W. a Y Y.) III yes. awe wa aM date, d MIYKM
<br />No
<br />Clarence Wegenast
<br />1% INFORMANT MAIUNIADDRESS ISTREETORRFO NO..CITYORTOWN. STATE ZIP)
<br />2507 W. Charles, Grand Island, NE. 68803
<br />20. EMBALMER - SIGNAT &LICE SE NO.
<br />�'l (%
<br />21a METHOD OFO EPOSITION
<br />211. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />p
<br />P a (d
<br />®Bea ❑R.moval
<br />June 14, 2001
<br />Glenvil Cemetery
<br />21a FUNERAL HOME -NAM
<br />CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑Lramapn ❑Donald,
<br />Glenvil, Nebraska
<br />220 FUNERAL HOME ADDRESS (STREET OR R F. D. NO. CITY OR TOWN STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE
<br />ONLY PER ial.Io AND Ul I Interval behaftn�onaamm�ano ni
<br />PARTl
<br />//+ )(ENTER /OON'ECCAUSE (LINE �FOR
<br />C_ l_Q
<br />DUE TO OR AS A CONSEOOENCE OF Inbaa waft aM Seam
<br />bl
<br />DUE TO OR AS A CONSEQUENCE OF Mbrvel belaaen eras aM Seam
<br />Icl 1
<br />OTHER SIGNIFICANT, - Cendi imecoeibNing So INS di but no reland PART
<br />III IF FEMALE WAS TMEREA 2<
<br />AUTOPSY 25. WAS LASE REFERRED TO MEDICAL
<br />(CONDITIONS
<br />PART V ✓K... PREGNANCY
<br />IN THE PASTJMONTH9
<br />E %AMINER OD CORONER?
<br />(Apes
<br />10 `A Y. NO
<br />Yee NO Yea NO
<br />Ma.
<br />2M. OATEQFINJURY (MO. Day Y[/
<br />26c. HOUROFINJUPY
<br />2M. DESCRIBEHOWINJORYOCOURRED
<br />AcciMnl ❑ Unotafto ed
<br />M
<br />SIxide Lj Pa.np
<br />26e . INJURY AT WORK
<br />26td1CL% I�W„RY;Al lane. term . street achy
<br />M WM
<br />26g. LOCATION STREET OR RFD. NO. CITY OR TOWN STATE
<br />0 He.." Imndi,st.
<br />YB, ❑ NO 1:1
<br />>4Med
<br />27a DATE OF DEATH (MO. My Yc)
<br />26a. DATE SIGNED 1M0 Day Ycl
<br />2W TIME OF DEATH
<br />0
<br />,S
<br />271 DATE SIGNED (MO(..�MyN;
<br />27c TIME
<br />28c PRONOUNCED DEAD (Me My. Yr.l
<br />281 PRONOUNCED DEAD (Imi
<br />Su{
<br />LC
<br />2
<br />/OF�DEATT`H�/\ {/-a}
<br />, 1 M
<br />._
<br />M
<br />2N1 TO Ne beat to my knowledge. 4gonEZERred atlas brat daft and gaze alp due lD Ile
<br />2M. On Meb isdexann. l' IaM,a nvMlipatal ,inmy0pnwndeaOwcwredal
<br />.°.
<br />cawslaaed.
<br />6
<br />Na eme.Mft Nd dace aM pabdN CaueNa)sM1ed.
<br />. aM TYb
<br />S awe aM Tae
<br />29 . DID TOBACCO USE CONTRIBUTE TO THE MAIN? a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED+
<br />30.b WAS CONSENT GRANTEDO
<br />❑ YES 9 NO ❑ UNKNOWN ❑ YES ® NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY, lTyppPriml
<br />Richard Fruehling M.D. 2116 W. Faidley, Grand Island,NE. 68803
<br />32A REGISTRAR
<br />321. DATE FILED BY REGISTRAR (Me pay Yq
<br />JUN 1 8 dal
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