|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISEp 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, WHICQH IS THE LEG1AL DEPOSITORY FOIE VJT;r,4.E 'R~CQRDS. .
<br />DATE OF ISSUANCE ~ O o " o ~ ~ ~ j ~ R..i ;~'
<br />o7,z„2oa~ 2 0 0 90 ~ s 4 ~ ~ ~: d~~~~~R:
<br />D>'~.9 I t T~k f, SAE i'H: Al ~lD:
<br />LINCOLN, NEBRASKA H-,~M.4N S~'tVIC'ES ~ ~ ; ~"
<br />STATE OF NEBRASKA - pEPARTMENT OF HEALTH ANU HUMAN SERViEE3 P~ ~~ ~~.,~~~;". ~`W`~~ *y
<br />CERTIFICATE OF DEATH ~ 09 01534
<br />~~.'>
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Y. SEX ' 1 w ./ ! . gATF F DE74TH (Mo., Day, Yr.)
<br /> Kenneth K Tweedy Male t `. ' ~ - July9; 20D9
<br /> 4. CITY AND STATE pR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 6. UNDER 1 YEAR SC. UNDER 7 DAY 8. DATE OF BIRTH (Mp„ pay, Yr,)
<br /> IY-ad MOS. DAYS HOURS MINE.
<br /> Phillipsburg, Kansas 72 June 3, 1937
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 509-34-5123 HOSPITAL ^ Inpatlant QjJ~ ^ Nursing Home/LTC ^ Hospice Facility
<br /> 8b. FACILITY•NAME (K not Inatitutlon, glue attest and number) [] ER/Outpatlent ®Dacedern's Homa
<br />LY
<br />324 Campbell
<br />^ f10A ^ Other (Specify)
<br />~ 8c. CITY OR TOWN OF DEATH pnclude Zip Code) Sd. COUNTY OF DEATH
<br />p Doniphan 138832 Hall
<br />~ 9a. RESIDENCESTATE 9b. COUNTY 90. CITY OR TOWN
<br /> Nebraska Hall Doniphan
<br />LL 9d. STREET AND NUMBER e. APT. NO. 9f. ZIP CODE 9g. INSlpli CITY LIMITS
<br />5. 324 Cam bell 68832 ^ YES ®No
<br />a 10a. MARITAL STATUS AT TIME OF DEATH ®Marrled ^ Never Nettled 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) ff wHa, give maiden name
<br />!E
<br />
<br />`m ^ Man•Ied, but separated ^ Wldowad ^ Divorced ©Unknown
<br />Patricia A Roberts
<br /> 11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br /> Frank Arthur Tweedy Winifred Jacobs
<br />a
<br />E 13. EVER IN V.S. ARMED FORCES? Give dates of service H Yps. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yps, No, or unk.) No Patricia A Tweed Wife
<br />$' 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. LICENSE NO. 18c. BATE (Mp., Day, Yr.)
<br />tie„ ®Burial ^ Donation
<br />Michael Butler
<br />0848
<br />Jul
<br />13
<br />2009
<br /> y
<br />,
<br /> ^ Crematlpn ^ Entombment
<br /> 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Fairview Cemetery Phillipsburg Kansas
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 176. Zip Code
<br /> Olliff-Boeve Memorial Cha el 1115 2nd Street PO Box 563 Philll sbur Kansas 67661
<br /> AU E DE H ee nstruct ens an exam e$
<br /> 1a. PART I. Enter the chain of ewnta-dlsaaasa, InJudea, or compllratlOns-that dlroCtly Caused the deattl. OD NOT antrr WrmMfl rwnta such as ardlac amrt, ) AppROXIAAATE INTERVAL
<br /> nopintory arrool, or vaMdcular flbrlllatlon without ahowlnq [ha etiology. p0 NOT ABBREVIATE. Einar only ono cauw on a line. Add addttlonal Iinoa tt noumry.
<br /> IMMEDIATE CAUSE: onset tp death
<br /> IMMEDIATE CAUSE (Final a) Respiratory Failure 3 Hours
<br /> dlaesee or CCndltlpn rosultlnq
<br /> m deaths DUE Tp, OR AS A CONSEQUENCE OFi ; pnsat to death
<br /> 5oyuvMlalty list cDUalliern, IF t)) - -
<br /> any, loading to the cauw Ilahd
<br /> on nn. a. DUE TO, OR AS A CONSEQUENCE OF; onset to dwth
<br /> Eerier the UNDERLYING CAUSE C)
<br /> Idlwase or Irt)ury that Inttiated
<br /> the eveMe reauttlnq In death( DUE 70, OR A5 A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 18. PART I1. OTHER SIGNIFICANT CONDITIONS-Condltlons contributing tp the death but not resulting In the underlyln0 cause ylven In PART 1. 19. WAS MEDICAL EXAMINER
<br /> Mesotheli0ma OR CORONER CONTACTED?
<br />~ ^ YES ®NO
<br />~
<br />LL O. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not pregnant wkhin paM year ®Natural ^ Homicide ^ Drlwr/Operator
<br /> ^ yES ® NO
<br />~ ^ Pregnant at time of death ^ AcGdent ^ Pandlnq Invaipgatlon ^ Paaaangsr
<br />
<br />a ^ Not Prognant, but Prognant wkhin 42 days Of death
<br />©Suiclda ^ Could not ha determined ^ Pedaatdan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />~
<br />^ Not pregnant, 6u[ prognaM 4a days to 1 year 6eforo death
<br />^ Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br /> ^ Unknown If pregnant wkhin the past year ^ YE$ ^ NO
<br />p•
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, construction alts, etc. (Speclty-
<br />c~
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />Q
<br />~
<br />^ YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP COPE
<br /> 28a. DATE OF pEATH (MO., Day, Yr.) _ ~ 24a. DATE SIGNED (Mo., Day, Yc) 24b. TIME pF bEATH
<br /> ~ 3 July 9, 2009 ~ ~ Z
<br /> 9
<br />23b, DATE SIGNl2p (Mo., Day, Yr.) 23c. TIME OF DEATH ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~ ~
<br />= Jul 10 2009. __.. - _._
<br />01:58 PM ~
<br />~
<br />~ e,
<br />_
<br /> _ Q sd. To the beat pf my knawleoge, death occurred at the dose, date and plaCa~
<br />~
<br />g ~
<br />z
<br />~ ~ 2~a. Dn the baala of examination and/or Inwatigadon, In my opinion death occurred at
<br /> and due to the Cauaela) stated. (Slgnaturo and Tkb)
<br />~
<br />~ ~
<br />~ ~ a the time, date and play and due to the Causalal stated. (Slgnaturo and Tnls)
<br /> .
<br />-haul Wibbels, MD
<br /> 2S. DID TOBACCO USE CONTRIBUTE TO THE DEATHS 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WA5 CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ®YES ^ NO Not Applicable N 28a Ia Np ^ YES ®NO
<br /> • ype Or t
<br /> Paul Wibbels, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901
<br /> 28a. REGISTRAR'S SIGNATURE x8b. DATE FILEp BY REGISTRAR (Mo., Day, Yr.)
<br /> July 15, 2009
<br />
|