|
..
<br />
<br />STATE OF NEBRASKA
<br />,~
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH r.ANL~"F'I&llr6 SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA=SK,4 PSI pT~7~t~F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOl7;-1%I~~F,~4~~EGG3RQ~ ~}rit ~d
<br />,~:~~~~,
<br />DATE OF ISSUANCE
<br />' tW ~p
<br />you ~ `~ zaUa 2 010 014 "j 5 Sy'.rANtE1'~ . CO()PEf2 ~ f~, ~ .
<br />ls~r~rA T R~GxS7" ;;
<br />~E RTM~I~H~~L~;H ,411f~ °"'
<br />LINCOLN, NEBRASKA ~~l~l%V SERVI~~S ~ ~ `~
<br />C~ •. r~ . c~ ,.+
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND Hl1MAN $ERV,IC~"~, -• -~~~C-~ • ~~'~. J
<br />RFRTIFIRATF fllc r1FATW ,C'.. ' .l
<br /> 1. DECEDENTS-NAME (First, Mlddle, Last, Suffix) 2. SEX L ^ 3 O$F,REA~ ~ MowDey,Yr.)
<br />v. r ~~.„
<br /> Merle Keith Weerheim Male ~ibriembe'r-~;"2008
<br /> 4, CITY AND STATE DR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE-Lear Birthday 6b. UNDER 1 YEAR 6c. UNDER 7 DAY a; DdTEOF BIRTH (Mo., Day, YrJ
<br /> (Yn.) MOS. DAYS HOURS MINS.
<br /> Corsica, South Dakpta 81 September 8, 1927
<br /> 7. SDCWL SECURITY NUMBER 9a. PLACE OF DEATH
<br />~ 5D3-24-9444 HOSPITAL: ®Inpatlant Q]'j~(g ^ Nunlnq WOmdLTC ^ HOapICe Facility
<br /> ab. FACILITY-NAME (If not Inatltugon, plus street rnd number) ^ ER/OutpaUsnt ~ Decedent's Home
<br />v
<br />Saint Francis Medical Center
<br />^ ooA ^other(SpaclTy)
<br />
<br /> Bc. CITY OR TOWN OF DEATH (Include Zlp Cade) ed. COUNTY DF DEATH
<br />to Grand Island 88803 Hall
<br />Z
<br />7 9a. RESIDONCESTATO 8b. COUNTY ae. CITY OR 7pWN
<br />LL
<br />~,
<br />Nebraska
<br />Hall
<br />Grand Island
<br />
<br /> 9d. STREET AND NUMBER 9e. APT. NO. >N. ZIP GODS Ap. INSIDE CITt' LIMITS
<br />!~ 308 W. 10th 5t. 88801 ®Y.a ^ ND
<br /> toe. MARITAL STATUS AT TIME OF DEATH ®MAMBd ^ Never MAMed 104. NAME OF SPOUSE (Ping Mlddle, Last, SuMI%) If wlh, give maiden name.
<br /> ^ Merrtad, but separated ^ Widowed ^ Divorced ^ Unknown .SUe Marie Ehrisman
<br />a 11. FATHER'S•NAME (First, Mlddle, Laat, Suffix) 12 MOTHER'S-NAME (First, Middta, Malden Surname)
<br />O
<br />~
<br />Jacob Weerheim
<br />Velma Putzier
<br />y
<br />m 13. EVER IN U.S. ARMEp FORCES? slue dates of service if Yer. 14a. INFORMANT-NANO 14b. RELATIONSHIP TO DECEDENT
<br />O
<br />~
<br />(Yes, No, or unk.) Yes 01!0911 -03!2111947
<br />Sue Mari Weerheim
<br />Wife
<br /> ib. METHOD OF DISPOSITION 1 . E ALMOR-SI f: ~ 1sb. LICENSE N0. 1ac. OATH (Mo., Day, Yr.)
<br /> ®Budal ^bonatlan
<br />~ /
<br />f~ ~
<br />November 7, 2008
<br /> panmaeaa ^Emslalxn.ar _
<br /> ^Removal ^omsryapsdryl iad. CEMETERY, CREMATORY OR OTHER L ATION CITylTOWN STATE
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 77s, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stara) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH See Instructions and exam les
<br />_ ,_ 70.YMI71. EMlr uN diBUeq, IryuMS, w CgmpllC~tlOna-fhn dlr~Etly Ceund the de.th, p0 NpT en4r Ntminal.wnp such es wMlae amla~ APPROXIMATE INTERVAL
<br />-_ _- -.-._ _..,t~ ~ _ _ -~ _ .`. ._ ~-
<br /> naplneory amp, yr uNr nhr111e11ohwltllaul aharMna ar ellolaay. oo NoT AeeaeVNT~7lli[B oNyoni draw on il~m~dTiadRfonaTl(nulrr~aiaiiry.
<br />1
<br /> IMMEDIATE CAUSE: I Onset tD death
<br />1
<br /> IMMEDIATE CAUSO (Final ~ "' I
<br />dlaua or candltlon naultin
<br />y'~/ti@~
<br />(
<br />~ /
<br />+
<br />a) ~ ~d~
<br /> q
<br />,
<br />,
<br />,~,
<br />~
<br />7,,c...~
<br />in death)
<br /> DUE Tq, pR AS A CONSEQUENCE OF: ~ Onset to death
<br /> Sequentially Ilat condidona, H I 'V V "`"C~
<br />6) ~~ ~ ~~~ I
<br /> any, leading to the cause listed
<br /> on Ilne a. DUE Tq, pR AS A CONSEQUENCE OF: ~ onset to death
<br /> 1
<br />/~ ~'~ ,l , rf ,., / 1
<br />Enter the UNDERLYING CAUSE c) L.-L~'!.-~t.LL'. J v"c-~' G~dC,Q.-~y~.- 4 ~ ,~„r~„~ ~ I ~,p
<br /> 1
<br />(disease or In)ury that Initiated ,
<br /> the events roaultinp In death) DUE T0, tlR A5 A CONSEQUENCE OF: I Onset to death
<br /> LAST ~
<br /> 1
<br />d) I
<br /> 18. PART IL OTHER SIGNIFICANT CONDITtONS~GondlUons conlrlbutlnp to the death but net resulting In the underlying cause Alvan In PART 1. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER
<br />C
<br />ONTACTOD9
<br /> `
<br />/
<br />^ YES ~A NO
<br />"
<br />'
<br />~ ~+
<br />,
<br />W 2a. IF FEMALE: 21 a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21 c. WA8 AN AUTOPSY PERFORMED?
<br />LL
<br />~
<br />^ Not pregnant within peat yur
<br />^ Neturel ^ Homicide
<br />^ DdveNOpentor
<br />^YES ~NO
<br />W ^ Pnpmnt at time of death ^ Accident ^ Pendlnp Investipatlon ^ Passenger
<br />
<br />V
<br />^Not pregnant, but pregnant within 42 days of death
<br />^ Su1Wde ^ COUId not 6a dalermined
<br />^ Pedestrian 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATHT
<br />,p ^ NOt prapnan6 but pregnant 49 days to 1 year 6efon dulh ©Othar (Specify) ©YES ^ ND
<br />y ^Unknown If pregnant within the pest year
<br />
<br />Rl
<br />Ir
<br />22a. DATE OF INJURY (Mo., Day, Yc)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURYv4t home, farm, street, factory, ofnce building, canatrucgan alto, etc. (Specify)
<br />O
<br />V
<br />m
<br />
<br />O 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCGURRED
<br />("' ^YES ^ ND
<br /> 22f. LOCATIpN OF INJURY - STREET S NUMBER, APT. NO. CITyITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Dry, Yr.) 24b. TIME OF DEATH
<br /> a~ November 4 2p08 a'v~z' m
<br /> Z4c. PRONOUNCED DEAD (Mo., Day, Yn) 24d. TIME PRONOUNGED DEAp
<br />} 23b. DATE SIGNED (Mo., Day, YrJ 23c. TIME pF DEATH ~ ~ ~
<br /> }
<br />E~z /-ic-a~ 11;13 a.m ~r,`i m
<br /> ~O o ~ O
<br />~
<br /> j 24e. On the barie oT examination endlor Invasdpadon, In my Oplnlon death Occumd
<br />23d, To the bas! my knowledge, death occurred a! the Ume, date and place ~ y
<br /> d~ tdlh ca se(a) stated. (Signature and TIUe) o ~ V at the Uma, data and place and due to the cause(s) sutad. (Signature and Title)
<br />and
<br /> /
<br />
<br /> 26. DID TOBACCp U E CONTRIBUTE Tp THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN GONSIDEREDT tab. WAS CONSENT GRANTED?
<br /> ^ YES ~NO ^ PROBABLY ^ UNKNOWN ^YES NO Not Applicable H 26e is NO ^YES ^ NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CgRONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type Or Pdnt)
<br /> Jay Anderson M.D. 729 N. Custer Ave. Grand Island Nebraska 68803
<br /> 28a. REGISTRAR'S SIGNATURE tab. DATE FILED SY REGISTRAR (Mo., Dry, Yr.)
<br />P Gov y ~ 2oos
<br />U
<br />
|