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STAtE OF NEBRASKA
<br />WHEN 't"HIS �OPY CARRIES THE RAISED $EAL OF THE NEBRASKA DEPARTMENT OF
<br />TNE BEL.OW TfJ� 8�' A 7RUE COPY OF THE ORIGINAL RECORD ON FI(�' WITH-THE NE
<br />HUMAN SERVICES, VITAL RECORDS bFFICE, WHICH IS THE L.E'GAL dEPOS1TORY F(
<br />DATE OF ISSUANCE r I
<br />5
<br />` ,1UL 2 9 2011 . A,
<br />p;
<br />LINCOLN, N
<br />t. DBCEPENTB-NA6fE {FI
<br />d. OITY AND STATE OH TEpR
<br />Wahoo, NE.
<br />7. socw. sECUairr au�e�
<br />505-54-1693
<br />8b. PACI6ITY.NAA9E pi n
<br />Golden Linin
<br />Ba CI7Y OATOWN OF DEATH pnclude Zlp Codej
<br />Be.HE81DENGE�TATE - 8b,t�UMY
<br />�', � HB�.�
<br />ad.sra�rarroNitr�a
<br />i23 E. Memoxial Drive
<br />10a. MARITAL BTATUS ATTIME 0F OEATH �Merrled O Nerer Martted
<br />❑ Marrled� bul aepareted 0 WMoared O Dicoreed � Urdcnatcn
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<br />t& EVERIN U.8. ARfdED FORCEB? (iive Qetas ot aeroice B yes. 14a. IN
<br />I�rea,r%munk.l P10 Gr�
<br />16. METHOD OF DISPOSITION
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<br />❑Cremalion dEntom�nenl
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<br />Oeceola Cemete'
<br />- 77aFUNEPALHOME.MAMEANDMAWN�ADDRE83 (BUeet;CHywTow
<br />Mlddie, � Melden Suroeme) �
<br />I. Rogers
<br />� 14b.RELATIQNBHIPTODECEDENT
<br />xusband
<br />18c. DATE �Mo:; Oay, Yr. )
<br />Au . 18, 2009
<br />STATE
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<br />. .. 17b: ZIP Code
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<br />7�fl���l�I1VL��, ` RI/ICES, IT CERTIFIES
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<br />72a. DATB OF INJURY (MO.. l)ay, Yr.1 �.'f�bE OF INJURY � 22a PLACH oF INJURWAt iiome, farm, etreet, faetorp ot4ee buildln& aonatrucdon site, ela {Spedy?
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<br />2Zd INJURYATWORK9 22e. DESCRIBE HQW INJUAY OCCURHED
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<br />22L LOCATION OF INJUFiY • 5THEET 8 tdUMBER. APt NO. � . CRYlI'OYVN 9TiIIE ZIPCOOE
<br />23a.DATEOFUEATH (Ma.Day,Yr.) 24aDATE910NED (Mo.,Dey.Yr.J 246.TIMEOFDFATFt
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<br />� �$ � the tlme, dete mid place and due m the oauee(s) ateted♦ (6igireture and Tftle �♦
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<br />�6a.HABOR�ANORTISSUH00NATl •BEENCONBI6EREQ4 .�286.WASCONBENT�RANTE09 /
<br />❑ YE8 �M1VO - Not ApptleaDle If 28e Ie NO O YEB 1dN0
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<br />ha str�et �tana Is r1E s8sa3
<br />26D. DATE FlLEO BY REQIBTRAR (Mo., Day.YcJ
<br />+� ,�. AUG 21 2009
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<br />HH9-81 t1/03 (68081)
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<br />$1 YES 0 no
<br />EBRASKA �� � 1 � � 'I � �� H�7�M�SERVICESfr'��� '
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<br />STATE OF NEBRASKA— DEPAHTMENT QF HEALTH AND HUMAN BERVICES FINANCE AND SUPPO 2 �
<br />CERTIFICATE OF DEATIi � 7� e`�����
<br />ret, Mlddie, Leat, SuHix) E. BEX 3;ffATEOFDEATH i�1o.,Day.Yr.�
<br />tt Marcelene Wieseman � Female Au . 14, 2009
<br />ITORY. OR FOREI�N COUNTRY OF BIRTH Be. AQE-Lest Birthday Bb. UNDEH 1 YEAR 5a UNDER 1 DAY B. DATE OF B1RTH (Ma, paq, Yr.�
<br />(Yra.) ' MOB: OAYS HOURS MINS.
<br />65 Aug. 1, 1.944
<br />eaa�nceoF�arH
<br />HOSPITAL• � O �npeAent QIH�i f�Nuraing Home1LTC O Hospke Pecmlq
<br />ot Inatttution, glve 9treet and number) p�yp��paUent O Decedanl'eHume
<br />g Center Lakeview o ocx O rnn�cs�
<br />1Ba LAdER-SIONHTUqE
<br />�. �•t,c_.�t,v�.r,t��
<br />16d CEMETERY, CREbU1TORY OR OTHEH LOCATION
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