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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ' "AN HtJk4N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA 'DEPARTMENT' °r HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL REC(QRDS.
<br />DID TOBACCO USE
<br />YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />• LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />CrflrfOWN
<br />Grand Island
<br />24c. PRONOUNCED DEAD (Mo., Day. Yr.)
<br />❑ H•wla•F«•ly
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the bats of exenNn.Non andlor bwasepegon, I n Dn opinion death occurred
<br />s e e s at the Erne, date end place and did to the cause(*) stated. (Signeture end T'RN)
<br />.o
<br />I
<br />DATE OF ISSUANCE
<br />01/09/2014
<br />LINCOLN, NEBRASKA
<br />1.DECEDENTS-NAME (Flret, Middle, jLaM, Saki
<br />Ted LeRoy Merithew
<br />CRY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-36 -1298
<br />UTY.NIIIIE (If not institution, give street and amber)
<br />Veterans Affairs Medical Center
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Sa. RESIDENCE STATE
<br />Nebraska
<br />COUNTY
<br />Hall
<br />3d. STREET AND NUMBER
<br />4357 Lariat Lane
<br />10.. MARITAL STATUS AT TIME OF DEATH NI Married :❑ New M an
<br />❑ Muted, but esp•retsd 0 Widowed 0 Divorced 0 Unknown :.
<br />11. FATHEt'$•NAME (First, : Middw, Last, Suffix)
<br />Fredniek Arthur Merithew
<br />to METHOD OF DISPOSITION lea UMSR- SIGNA
<br />al Budd ❑Dsnren
<br />not
<br />D istend Q°tlw(ea•Ih)
<br />Sequentially list conditions, If .
<br />any. lauding to the cease Sated
<br />ongns..
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />25..: REGISTRAR'S SIGNATURE
<br />b)
<br />Enter the UNDERLYING CAUSE 0)
<br />(disease or many that Meted DUE TO.
<br />the events resulting in dMI).
<br />LAST
<br />OR AS A CONSEQUENCE OF:
<br />20. IF FEMALE:
<br />O Not pregnant wlfffb past ysar
<br />CI Preempt *Undo of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown If pregnant within the pest year
<br />• DATE OF INJURY (Moe, Dry, Yr.)
<br />23a DATE OF DEATH (Mo., Day, V .)
<br />1►. = t,,
<br />2014011 42
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES,
<br />CERTIFICATE OF DEATH
<br />2. SEX
<br />Male
<br />Le. UNDER 1 YEAR' „. Sc. UNDER 1 DAY
<br />Ea. AGE- a t Birthday
<br />(aim•)
<br />80
<br />13. EVER IN U.S. ARMED FORCES? Ole dabs of winks II Yes. 14e.INFORMANT•NAME
<br />(Yea, No. oruail.) Yes 03/311953 Mary Ellen Merithew
<br />led. CEMETER'Y,: CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Ebb}
<br />Apfel Funeral Home, 1123 W. 2nd, Grand island, Nebraska
<br />Of:
<br />21e. MANNER OF DEATH
<br />QSabinl ❑ Humid .
<br />❑ Accident ❑ Pending bwesdpatlaf
<br />❑ SuIcId. ❑ Could web' determined
<br />250. DATE SIGNED'(Mo., Day, Yr.)
<br />Ili IA
<br />• the been Of my . e. death occur ed at the Item, date and pfeee
<br />� o auea(s) stated. (Signature and Tilt.)
<br />M4„•
<br />MOB.
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />Ss. PLACE OF DEATH
<br />BOMA ID moose
<br />❑ WUOuWeINnt
<br />❑ DOA
<br />DAYS
<br />10p.
<br />132$
<br />IMMEDIATE CAUSE (Final -_\ h�����
<br />In death) « aondNbn reesbno : N n t l � � g y \'C Q � ( "A N i.: \\ L f e
<br />DUE TO, OR ASACONIEOUENCEOF: `(
<br />\Ci s to
<br />DUE TO, OR AS A CONSEQUENCE
<br />25s. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES IKNO
<br />SPANLE $. COQPE • o�
<br />;ASSISTITSfAISTf1RA
<br />sDtPARTMENT OF HEALTH Alp-
<br />'� Ilfil�1AN SERVICES
<br />, � L'
<br />f i
<br />HOURS
<br />MEN.
<br />gitzg&0 Nursing Nomo/LTC
<br />Deadrrt's Home
<br />❑ 0110010080177)
<br />Id COUNTY OF DEATH
<br />Hall
<br />10b. NAME OF SPOUSE (Flat, Middle. Last.
<br />Mary Ellen Liens
<br />12. M071IER'SNAME (Phut, Middle
<br />Frances Amy Roark
<br />CAUSE OF DEATH (See Instruct ons and examples)
<br />II. Parr L 61,1., 5.e d. uwis dieeeeee, nor e. wkwiww. awe diimlyowe.din doilA 00 NO? .nrrt,rak,d made anh ,.ram ewe.
<br />n ruddy .ned,are.,.lAe.YrIL,S0asWON shadily the .NreOY. 00 NOT AISREW.TL Eder anti and deer en Inc Add eddtUaw 1Yne Nrww
<br />IMMEDIATE CAUSE:
<br />( 21b. IF TRANSPORTATION
<br />❑ onsmoosomme
<br />❑ Pa•elaK
<br />❑ Pedestrian
<br />❑ Oth.r(sp000y)
<br />24.. DATE SIGN (Mo, Day, Ye)
<br />SUMbr) If wife, give maiden name.
<br />Maiden Sanmma)
<br />111. PART It, OTHER SIG MrICANT COPLRIOI(S•CondMans crdrIbuting to the death but not resulting Inthe underlying caws given in PART L
<br />INJURY)
<br />STATE
<br />T 4 4
<br />S DATE OF DEATH (Mo..Da .YT.
<br />December 26, 2013
<br />8. DATE of BIRTH (Mo., Day, Yr.)
<br />February 22, 1933
<br />5g. INSIDE CITY UNITS
<br />® Y e. ❑ No
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />100. DATE (Mo, Dy. Yr.) :.
<br />December 31, 2013
<br />APPROXIMATE INTERVAL
<br />I onset to death
<br />i onsstlo death
<br />'.
<br />Nebraska
<br />alW lo death
<br />17b,Lp Cods
<br />68801
<br />111. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ Yes Ng No
<br />122b. TIME OF INJURY ( no. PLACE OF INJURY-At horn%farm, West, foolery, Wee buibbq, eaMpureon site, etc. (Specify)
<br />m
<br />MINI OF DEATH
<br />JAN r 2014
<br />ZIP CODE
<br />a to
<br />211b. DATE FRED BY REGISTRAR (11o., Day, Yr.)
<br />
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