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<br />200309891
<br />WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORDONF1L,E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC S D 1lCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />DATE OF ISSUANCE
<br />it OPEI
<br />7/7/2003 A$*s�ivr�iit�st�r
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND- SUPPORT
<br />VITAL STATISTICS = -_ 0 3 07389
<br />CERTIFICATE OF DEATH - _
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month Day. Year)
<br />Virgil Dale Weber
<br />Male
<br />June 28, 2003
<br />4. CITY AND STATE OF BIRTH /#not in U.S.A., name country)
<br />Sa. AGE - Last Birt hday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />St. Paul, Nebraska
<br />(Yrs.) 87 1 51b.
<br />m
<br />5c. HOURS' MINS
<br />March 11, 1916
<br />=D
<br />Ba. PLACE OF DEATH
<br />506 -05 -9779
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<br />❑ DOA ❑ Other(Specdo
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH
<br />an s n
<br />vas jg� No Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />gc. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />z
<br />Hall
<br />Grand Island
<br />1315 W. Koeni g it 68801
<br />Yes ® No ❑
<br />Z
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />12.)M MARRIED ❑ WIDOWED
<br />M
<br />H
<br />1.
<br />�_
<br />-I ri-I
<br />�+
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<br />. KIND OF BUSINESS INDUSTRY
<br />EDUCATION )Specify only highest grade completed)
<br />ofworkinglife, evenifrefired)
<br />Owner / Operator E'Beauty
<br />Sch ool
<br />�El eme ntary or Secondary 10 -12) College (1 -4 or 5-1
<br />8th Grade
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST. MIDDLE MAIDEN SURNAME
<br />Merle Weber
<br />Nora Wickstrom
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />co
<br />Yes II 11 -23- 1942/12 -1 -1944
<br />Evel n Weber
<br />y
<br />15 W. Koeni #2, Grand Island, Nebraska 68801
<br />20. ALMER •SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />. CEMETERY OR CREMATORY NAME
<br />_-
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<br />❑Cremakon ❑Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D, NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. IMMEDIATE CAUSE _ /y (ENTER /ONLY ONE CAUSE PER LINE FOR (a). Ibl, AND (c)I Inteeervvaall between onset and tleath
<br />k PART
<br />S 0 �'
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<br />(c) C_O r% l l 1(--
<br />=
<br />111 IF FEMALE. WAS THERE A 2a
<br />AUTOPSY
<br />5. WAS C E REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS? a'
<br />G
<br />(Ages
<br />_c 1 1
<br />N
<br />CD
<br />1
<br />26a.
<br />26b. DATE OF INJURY (Mo., Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJJRY OCCURRED
<br />Accident Undetermined
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<br />26e. INJURY AT WORK
<br />�Lqq EE
<br />26L pBlce b Qkliog URY _ A=e, farm, street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. .CITY OR TOWN STATE
<br />F1 Homicide Investigation
<br />Yes ❑ No ❑
<br />27a. DATE OF DDE)ATH (Mo.. Day. Yr,)
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<br />27b. DATE SI NED ( .. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yr.)
<br />28d. PRONOUNCED DEAD /Hours
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<br />27d. To the best of my knowledg Bath curred at the ti , date place arA due to the
<br />28e. On the basis of examination and, or investigation, in my opinion death occurred at
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<br />the time, date and place and due to the cause(s) stated.
<br />(Signature and Title) �
<br />(Signature and Title 0,
<br />29. DID TOBACCO USE CONTRIBUTE-TO THE IDEEAAATT�q? 30.a
<br />HAS TISSUE DONATION BEEN, CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />NO
<br />} ❑ YES ❑ NO V t�NKNOWN
<br />❑ YES O
<br />'!
<br />r ❑ YES
<br />31. NAME AND ADDRESS OF CERTIFIER IPH11Y✓/YSIICI"AN, CORONERS PHYSICIAN OR COUNTY(AT�TORNEYI (Type or Prrint/
<br />J/_' /
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<br />32a. REGISTRAR
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<br />32b. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />_0 1 _. __
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<br />y.,
<br />O d
<br />A 1
<br />S.
<br />u
<br />Q-
<br />J
<br />200309891
<br />WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORDONF1L,E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC S D 1lCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />DATE OF ISSUANCE
<br />it OPEI
<br />7/7/2003 A$*s�ivr�iit�st�r
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND- SUPPORT
<br />VITAL STATISTICS = -_ 0 3 07389
<br />CERTIFICATE OF DEATH - _
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month Day. Year)
<br />Virgil Dale Weber
<br />Male
<br />June 28, 2003
<br />4. CITY AND STATE OF BIRTH /#not in U.S.A., name country)
<br />Sa. AGE - Last Birt hday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Month. Day. Year)
<br />St. Paul, Nebraska
<br />(Yrs.) 87 1 51b.
<br />MOS. DAYS
<br />5c. HOURS' MINS
<br />March 11, 1916
<br />7. SOCIAL SECURTIY NUMBER
<br />Ba. PLACE OF DEATH
<br />506 -05 -9779
<br />HOSPITAL: ❑ Inpatient OTHER 19 Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />81b. FACILITY - Name (ll not rnsf/futlon, give street and number)
<br />St. Francis Skilled Care Center
<br />❑ DOA ❑ Other(Specdo
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH
<br />an s n
<br />vas jg� No Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />gc. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1315 W. Koeni g it 68801
<br />Yes ® No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />12.)M MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (/f wife. give maiden name/
<br />etc.) (Specify)
<br />White
<br />fSpeeify)
<br />American
<br />NEVER
<br />MggR DIVORCED
<br />Evel n Zimmerman
<br />14a. USUALOCCUPATION (Give rancor work done during most
<br />. KIND OF BUSINESS INDUSTRY
<br />EDUCATION )Specify only highest grade completed)
<br />ofworkinglife, evenifrefired)
<br />Owner / Operator E'Beauty
<br />Sch ool
<br />�El eme ntary or Secondary 10 -12) College (1 -4 or 5-1
<br />8th Grade
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST. MIDDLE MAIDEN SURNAME
<br />Merle Weber
<br />Nora Wickstrom
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />)Yes. no. or unk.) 0f yes. give war and dates of services)
<br />Yes II 11 -23- 1942/12 -1 -1944
<br />Evel n Weber
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO„ CITY OR TOWN, STATE. ZIP)
<br />15 W. Koeni #2, Grand Island, Nebraska 68801
<br />20. ALMER •SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />. CEMETERY OR CREMATORY NAME
<br />i Y
<br />/ / ,3
<br />EK Budal ❑ Removal
<br />Jul 1 2003 TWcestlawn
<br />Memorial Park
<br />22a. FUNERAL HOME -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H.
<br />❑Cremakon ❑Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D, NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />23. IMMEDIATE CAUSE _ /y (ENTER /ONLY ONE CAUSE PER LINE FOR (a). Ibl, AND (c)I Inteeervvaall between onset and tleath
<br />k PART
<br />S 0 �'
<br />I ✓L I .'� /� --Ik L4 f ,r
<br />DUE 70, OR AS A C )NSEOUE CE OF - Interval be n onset and death
<br />l
<br />c ci W� t.
<br />DUE TO, OR AS A CONSEQUENCE OF' Interval between onset and death
<br />I
<br />(c) C_O r% l l 1(--
<br />OTHER SIGNIFICANT CONDITIONS - Conditions corebuting to the death but not related PART
<br />111 IF FEMALE. WAS THERE A 2a
<br />AUTOPSY
<br />5. WAS C E REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS? a'
<br />EXAMINER OR CORONER?
<br />(Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes 0 No
<br />26a.
<br />26b. DATE OF INJURY (Mo., Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJJRY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />�Lqq EE
<br />26L pBlce b Qkliog URY _ A=e, farm, street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. .CITY OR TOWN STATE
<br />F1 Homicide Investigation
<br />Yes ❑ No ❑
<br />27a. DATE OF DDE)ATH (Mo.. Day. Yr,)
<br />28a. DATE SIGNED (Mo.. Day. Yr)
<br />28b. TIME OF DEATH
<br />k P LJ
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<br />27b. DATE SI NED ( .. Day. Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yr.)
<br />28d. PRONOUNCED DEAD /Hours
<br />C) rI M
<br />as
<br />Bwz°
<br />M
<br />27d. To the best of my knowledg Bath curred at the ti , date place arA due to the
<br />28e. On the basis of examination and, or investigation, in my opinion death occurred at
<br /><
<br />2 °
<br />r�use(s) stated.
<br />the time, date and place and due to the cause(s) stated.
<br />(Signature and Title) �
<br />(Signature and Title 0,
<br />29. DID TOBACCO USE CONTRIBUTE-TO THE IDEEAAATT�q? 30.a
<br />HAS TISSUE DONATION BEEN, CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />NO
<br />} ❑ YES ❑ NO V t�NKNOWN
<br />❑ YES O
<br />'!
<br />r ❑ YES
<br />31. NAME AND ADDRESS OF CERTIFIER IPH11Y✓/YSIICI"AN, CORONERS PHYSICIAN OR COUNTY(AT�TORNEYI (Type or Prrint/
<br />J/_' /
<br />f
<br />U. 7i! L7 W I K. f�. Y. Sit !.� ( ow tJ r'ZL �. �"'�'� 1 �-h (��
<br />32a. REGISTRAR
<br />1
<br />32b. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />_0 1 _. __
<br />Bova . o ) n m
<br />
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