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<br />Lecorder's Info: The Southeast Quarter of the Southeast Quarter (SE1 /4SE1/4) and Lots One (1) and Two (2),
<br />Island, in Section Twenty-three (23), Township Ten (10) North, Range Eleven (11) West of the 6th P.M., Hall
<br />County, Nebraska, excepting that part thereof conveyed to the State of Nebraska by deed recorded in Book 164 of
<br />Deeds, Page 322, together with all improvements and appurtenances thereunto belonging.
<br />736. 4/116063
<br />WWN THIS COPY CARRWS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT CERTIF,ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE£f!0N,-Wfflt�H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. %��,,r�
<br />DATE OF ISSUANCE _ I "� t*`
<br />tANLEY S. COOPER
<br />6/22/2004 200503860 ASSISUMT STATE- REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICI:5'F(TlANCE AND SUPPORT
<br />VITAL STATISTICS _
<br />CERTIFIC'ATF. OF nFATTT =
<br />�
<br />t. DECEDENT - NAME FIRST MIDDLE LAST 2
<br />2. SEX 3
<br />3. DATE OF DEATH /Monet. Day. Yaar/
<br />Donald Wiese M
<br />Male J
<br />June 16, 2004
<br />4, CITY AND STATE OF BIRTH Ilfnotin U.S.A.. name country) 5
<br />5a. AGE - Last Birthday U
<br />UNDER 1 YEAR U
<br />UNDER 1 DAY 6
<br />6. DATE OF BIRTH /Month. Day. Year/
<br />$b. MOS. DAYS S
<br />Sc. HOURS' MINS.
<br />Wood River, Nebraska 9
<br />(Yra.l $
<br />February 24, 1908
<br />7, SOCIAL SECURITY NUMBER B
<br />Be. PLACE OF DEATH
<br />505-48-6270 H
<br />HOSPITAL ❑ Inpatient OTHER_: ® Nursing Home
<br />❑ ER Outpatient Residence
<br />fib. FACILITY - Name tit not insiftu6on, give street and number/ ❑
<br />Tiffany Square Care Center ❑
<br />❑ DOA ❑ OtherrSpecrtvt
<br />_ 8C. CITY. TOWN OR LOCATION OF DEATH 8
<br />8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH
<br />Grand .Island Y
<br />Yee No - Hall
<br />9a. RESIDENCE - STATE 9
<br />9b. COUNTY 9
<br />9c. CITY. TOWN OR LOCATION g
<br />go. STREET AND NUMBER (Including Zip C&8 803 9
<br />9e INSIDE CITY LIMITS
<br />Nebraska H
<br />Hall G
<br />Grand Island 13119 W
<br />W. Faidley Ave. Y
<br />Yes No ❑
<br />10. RACE - (e.g., White. Black. American Indian. 1
<br />11. ANCESTRY (e.g.. Italian, Mexican. German, efel 1
<br />12. ❑MARRIED n WIDOWED 1
<br />13 NAME OF SPOUSE tit wde. grve marden name)
<br />etc.) (Specify) (
<br />(Specify) N
<br />NEVER DIVORCED
<br />Nora N. Moeller (Dec)
<br />MA N
<br />14a. USUAL OCCUPATION rGive kind of work done during most 1
<br />14b. KIND OF BUSINESS INDUSTRY 1
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even I /refired/ E
<br />Agriculture 8
<br />Elemen ery or Secondary I0 -121 College 11 -4 or 5 -I
<br />16. FATHER -NAME FIRST MIDDLE LAST 1
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME.
<br />Emil Wiese E
<br />Emma Kay
<br />18. WAS DECEASED E
<br />EVER IN U.S. ARMED FORCES? 1
<br />19a. INFORMANT - NAME -�
<br />(Yes, no. or unk.) (
<br />(If yes. give war and dates of services)
<br />N I
<br />I --- - --- -- M
<br />Marlene Fuehrer
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />4302 Stonerid e Path, Grand Island, Nebraska 68801
<br />.20.E L R - SIGNAT E & ENSE NO. y /
<br />21 a. METHOD OF DISPOSITION 2
<br />21b. DATE 210. C
<br />CEMETERY OR CREMATORY NAME
<br />/ 2
<br />[36urisl 11 Removal J
<br />June 19, 2004 W
<br />Westlawn Memorial Park
<br />22a. FUNERAL HOW- NAME 2
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sondermann F.H. ❑
<br />❑Crematlon ❑Donatron G
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, TIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />PART , L b I � I� 1 1 'V_
<br />DUE T0, OR AS h CONSEQUENCE OF Interval between onset and death
<br />(b)
<br />I
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death �.
<br />(c)
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contrlbuting to the death but not related PART "'IF FEMALE. WAS THERE A 24 AUTOPSY 25, =ERE REFERRED TO MEDICAL
<br />I PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER?
<br />(Ages 10 -541 Yes Np Ves Np Yes No
<br />28a. 26b. DATE OF IN RY (MO.. Day. Yr.) 260. HOUR OF INJ 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident ❑ Undetermined M
<br />Suwide ❑ Pending 260. INJURY AT WORK 26f. PLACE OF INJURY -At hom . farm. street, factory 26g. LOCATION STREET OR R.F.O. NO. CITY OR TOWN
<br />❑F-] ❑ office building, etc. (SpeciN
<br />Homicide Investigation yg5 NO
<br />STATE
<br />27a. DATE OF DEATH tW.. Day. Yr) 2Ba. DATE SIGNED (Mo,, Day. Yr.) 28b TIME OF DEATH
<br />�= June 16, 2004
<br />a '- a s M
<br />a-i 276. DATE SIGNED /MO.. Day. Yr) 27c, TIME OF DEATH � i G 28c� PRONOUNCED DEAD /Mo.. Day, Yc) 28d. PRONOUNCED DEAD (Hour)
<br />09:40 P.M. U �
<br />g� M �, pW M
<br />27d. To the best df my knowledge, odeurr at the tirpe, date and place and due to the L1 S 280. On the basis of examination andor investigation, in my opinion death occurred at
<br />.�causels) stated. 5 the time, date and place and due to the causels) stated.
<br />ISi nature and Title Signature and Title) ►
<br />29. DID TOBACCO USE CONTRIBU7 THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN C SIDERED? 30•b WAS CONSENT GRANTED?
<br />'X ❑ YES ND ❑ UNKNOWN x- ❑ YE5 ND 4- YES 15NO
<br />31.. N,ANQ ADDRESS OF CERTIFIER (PHZSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type dr Print/
<br />32a, REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />J JUN 21 2004
<br />`5 -`S U
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