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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOIarVITiAE'R~CQRDS:
<br />~~, ~.
<br />DATE OF ISSUANCE '~
<br />o7iz~ izoos 2 4 0 9 4 7 9 4'7 ~rQ~L~Y ~• ~R~~ _~
<br />ASSTST A,~E. f~EG~Sl'RAR
<br />DEPi9 R 7•i~F~~ 9r'Tii: AlG`D`~
<br />LINCOLN, NEBRASKA H(7M•4/~`S~RV~CES , ;
<br />57ATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERViIE~S~"'tr:' ~' `l `
<br />CERTIFICATE OF DEATH • „'r'' •~''~+ I ~ ~ ~ 09 01534
<br /> 1. DECEDENT'S•NAME (Firet, Middle, Last, Suffix) 2.5EX ~ i-, q ~- t; . DATF ~F PEIATH (Mo., Day, Yr.)
<br /> Kenneth K Tweed Male • July 9, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR sc. UNDER 1 DAY 8, DATE OF BIRTH (Mo., Day, Yr,)
<br /> (Yra.) MOS. DAYS HOURS MIN$.
<br /> Phillipsburg, Kansas 72 June 3, 1937
<br /> 7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br /> 509-34-5123 HOSPITAL ^ Inpatient QTHER ^ Nurelnp Home/LTC ^ Hospice Facility
<br /> 8b. FACILITY-NAME (If not Institution, give atreet and number) ^ ER/Otrtpathnt ®Dacadettra Nome
<br />~
<br />~ ;w^~~..~a.,....~:. .~. ....
<br />324 Gampbell ©DOA ^ Other (Specl-y)
<br />~ 8c. CITY OR TOWN pF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />~ Doniphan 68832 Hall
<br />a 9a. RESIDENCE•STATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Doniphan
<br />~ 8d. STREET AND NUMBER e. APT. NO. 9F. ZIP CODE 9g. INSIDE CITY LIMITS
<br />~` 324 Cam bell 68832 ^ YES ® No
<br />
<br /> 1oa. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 10b. NAME OF SPOUSE (First, Meddle, Last, Suffix) K wife, proa maiden name
<br />
<br />!` ^ Married, but separated ^ Widowed ^ Divorced ^ Unknown PatrlCla A RObertS
<br />d
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />~ Frank Arthur Tweedy Winifred Jacobs
<br />~'
<br />E 13. EVER IN U.S. ARMED FORCES? Glve dates of service ff Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, No, or Unk.) NO Patricia A Tweed Wife
<br />,°~ 15. METHOD OF DISPpSITION 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (MO., Day, Yr.)
<br />F ®Burlal ^ Donation Michael Butler 0848 July 13, 2009
<br /> ^ Cremation ^ Entombment 1gd. CEMETERY, CREMATORY OR pTHER LOCATION CITY / 70WN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Fairview Cemetery Phillipsburg Kansas
<br /> 77a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty Or Town, State) 176. Zlp Code
<br /> Olliff-Boeve Memorial Cha el 1115 2nd Street PO Box 563 Philli sbur Kansas fi7681
<br /> DEATH ee Instruct one and exam lee
<br /> ta. PART 1. enter the gJ]pjp„q)¢v4nt~dlaeasas, inludaa, or eomplieadons-that dlroctly cauaad the death. DO NOT enter terminal avsnta such as camlae arrest, ;APPROXIMATE INTERVAL
<br /> roaplrotory arrosl, OY ventricular flbdllatlon wtthout ahowinp the etiology. DO NOT A88REVUITE. Enter only ono cauw On a Ilea. Add addltlanal lines 11 neceswry.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE IFlnal a) Respiratory Failure ; 3 Hours
<br /> dlseaae or condition rosuttlnp
<br /> w death) DUE TO, OR AS A CONSEQUENCE OFc _ _ .. ' ~ ollaet tD death
<br /> 5eguenualry Ilat cendttlona, If bl
<br /> any, leading to the cause listed
<br /> on Ilne a. DUE TO, OR A3 A CONSEQUENCE OF: oruet to death
<br /> Eller the UNDERLYING CAUSE Cl
<br /> (dlaeass or InJury that Initiated
<br /> the events roaultinp In tlaatnJ DUE TO, OR AS A CONSEQUENCE OF: ~ onset to death
<br /> LAST d)
<br /> 18. PART II. pTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> MBSOtheli0m8 OR CORONER CONTACTED?
<br /> ^ YE5 ®Np
<br />K
<br />LL 20
<br />IF FEMALE: 21a. MANNER OF DEATH Z1b. IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMED?
<br />~ .
<br />^ Not pregnant within paq year ®Natural ^ Homicide ^ DWvarlOparator ^ YES ® NO
<br /> Pregnant a[ time of death
<br />^
<br />^ Accldanl ^ Pendin
<br />Irlvettigadon ^ Passenger
<br />~ ^ Not pregnant, but prognant within 4;Jaya o1 death g
<br />Suiclda Could not bs determined
<br />©
<br />^ ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE pF DEATH?
<br /> © Not prognant, but pregnant 49 day6 to 1 year 6afon death . ^ Other (SJxcify)
<br />~ ~ Unknown If pregnant wtthin the past year ^ YE$ ^ NO
<br />
<br />a
<br />E 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street. factory, office building, construction site, etc. (Specify)
<br />t~
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~
<br />^ YES ^ NO
<br /> 22f. LDCATIpN OF INJURY -STREET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br /> 28a. DATE OF DEATH (Mo., Day, Yr.) _ ~ 24a. DATE SIGNED (Mo., Day, Yr.) 246. TIME OF DEATH
<br /> ~ ~ July 9, 2009 3' ~ z
<br /> 23b. DATE SIGNED (Mo., Day, Yr.- 23c. TIME OF DEATH ~ 24c. PRONpUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAp
<br />
<br />d ~ y .
<br />Jul 10 2009 01:58 PM $g., ~ ,
<br />~
<br />~
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<br />a v sd. Yo the beat of my knowledge, death occurred at the time, date and place ° ~
<br />24e. On the 6aelaof axamination and/or Inveatigatlon, In my opinion death occ~rree at
<br />77
<br />(Signature and TItIa)
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<br /> ~ ~ Paul Wibbels, MD ~ ~ $
<br /> 25. DIP T peACCO USE CONTRIBUTE Tp THE DEATH? 28a. HAS pRGAN pR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ®YES ^ NO Not Appllcabla iF 26a Is NO ^ YES ®NO.
<br /> A E, TI R I (ype or r nt
<br /> Paul Wibbels, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 88901
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br /> July 15, 2009
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