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WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND <br />SYSTEM, R CERTIFIES TIC BELOW TO BE A TRUE COPY OF THE ORIGINAL REF <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST) :: <br />. <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />FEB 17 2000 200316369 ASS T <br />LINCOLN, NEBRASKA HEALTH AND HUMA <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERY:K_ <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />r l�r <br />1N CN E AIM SiH�ORT <br />_ 99 13628 <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX <br />3. DATE OF DEATH tMonrh Day Year) - <br />Robert John Woestman <br />Male <br />November 14, 1999 <br />4. CITY AND STATE OF BIRTH 11fnot in USA.. name countryl <br />5a. AGE - last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6, DATE OF BIRTH tMonM1. Day. Year) <br />MOS DAYS <br />5c HOURS MINS <br />Galesville, Wisconsin <br />(Yrs1 59 5b <br />June 1, 1940 <br />7 SOCIAL SECURITY NUMBER <br />_ <br />Sa PLACE OF DEATH <br />508 -40 -4622 <br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home <br />Q ER Outpatient ❑ Residence <br />8b. FACILITY - Name tlf nor institution, give street and number) <br />i St. Francis Medical Center <br />❑ DOA ❑ Other(Specifyi <br />Bc. CITY TOWN OR LOCATION OF DEATH <br />IM INSIDE CITY LIMITS <br />Ile. COUNTY OF DEATH <br />Grand Island <br />Yes %] No ❑ <br />Hall <br />9a RESIDENCE - STATE <br />9b COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Zip Code/ <br />9e Y LIMI TS <br />Nebraska <br />Hall <br />Grand Island <br />1906 S. Blaine 68801 <br />7NSID <br />No ❑ <br />10. RACE - (e.g., White. Black, American Indian <br />1 I. ANCESTRY le g, Italian. Mexican. German, etc) <br />1 2. ® MARRIED ❑ WIDOWED <br />13 NAME OF SPOUSE (If wile. give maiden name) <br />etc .I(Specify) White <br />(Specify) American <br />NEVER DIVORCED <br />MA I <br />Jeannie Lewandowski <br />14a USUAL OCCUPATION IGrye iloodo {work done during mos! 14b <br />KIND OF BUSINESS INDUSTRY <br />_ <br />15 EDUCATION (Specify only highest grade completed) <br />of working life. even if ebredl <br />Owner/Operator <br />Sheetmetal Business <br />Elementary or Se ondary 10 -12) College n -4 or 5.1 <br />1 __ <br />16. FATHER - NAME FIRST MIDDLE LAST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Howard Woestman <br />Elsie Becker <br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? <br />_ <br />1 9a.INFORMANT -NAME <br />(Yes no or unk.) III yes give war and dates of services) <br />No I <br />i Jeannie Woestman <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D NO.. CITY OR TOWN. STATE. ZIP) <br />1906 S. Blaine, Grand Island, NE 68801 <br />20 E ALMER - SIGNATURE 8 LIC SE NO <br />21a METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />a Burial ❑ Removal <br />Nov. 17, 1999 <br />Westlawn Memorial Park <br />2a FURERAL HOME - NAJW <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler- Geddes <br />❑ Cremation ❑ Dodalipn <br />Grand Island, Nebraska <br />22b 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 (ENTER ONLY ONE CAUSE PER LINE FOR (al. pl. AND (01 I Interval between onset and death <br />PART I <br />I <br />lal Cardio ulmonar arrest <br />DUE TO, OR AS A CON EOUENCE OF Interval between onset and death <br />I <br />I <br />ID! <br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset ,..id death <br />I <br />I <br />Icl _ <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER'! <br />II <br />(Ages <br />10 -54) Yes No <br />Yes No <br />Yes No El <br />26a <br />26b DATE OF INJURY (Mo. Day. Yr.) <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />❑ Acodent F] Undetermined <br />M <br />El Suicide n Pending <br />26e INJURY AT WORK <br />26f. PLACE OF INJURY -At home, farm, street. factory <br />26g LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />yes ❑ ❑ <br />o ice bwlding. etc. (Specify) <br />No <br />27a DATE OF DEATH (Mo Day. Yr.) <br />28a. DATE SIGNED (Mo.. Day Yr I 28b TIME OF DEATH <br />November 13 199 3:20 p M <br />27b. DATE SIGNED (Mo. Day Yr) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD tMo.. Day. YO 28d. PRONOUNCED DEAD (H-0 <br />I, <br />< <br />M <br />A"," <br />November 14 199 3:20 p M <br />27d To the best of my knowledge death occurred at the time, date and place add due to the <br />28e. On the basis of examination or investigation, in my opinion death occurred at <br />a <br />2 W ° <br />° = <br />cause(s) stated <br />the time. date and place the ausels) stated. <br />Signature and Title ► <br />(Signature and Title ) ► <br />DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />.b WA ON NTED? <br />129 <br />❑ YES ❑ NO R] - UNKNOWN <br />❑ YES R] NO <br />❑ y NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) IType a Print) <br />32a. REGISTRAR <br />32b DATE FILED BY REGISTRAR /Mo. Day Yr) <br />i <br />�i r <br />�j <br />L <br />