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DUE TO, OR AS A CONSEQUENCE OF: - (c) DECEDENT - NAME FIRST MIDDLE LAST Robert William Meyer 2. SEX Male 3. DATE OF DEATH !Month. Day. Year) April 9, 2003 4. CITY AND STATE OF BIRTH Id not in USA.. name country) Grand Island, Nebraska 5a. AGE - Last Birthday O 81 UNDER 1 YEAR UNDER 1 DAY 6, DATE OF BIRTH (Month. Oay. Year) August 31, 1921 5b. MOS DAYS 5c. HOURS MINS 7. 7. SOCIAL SECURTIY NUMBER 505 -18 -6867 11 8a . PLACE OF DEATH HOSPITAL: Inpatient OTHER: X Nursing Home 85. FACILITY - Name at not rnsE?ution, give street and number/ r Nm Tiffany Square Care Center ER Outpatient ❑ Residence ❑ DOA ❑ Other (Specify/ To be Completed by CORONERS PHYSICIAN a COUNTY ATTORNEY ONLY 28a. DATE SIGNED (Mo.. Day. Yr/ 8c. CITY. TOWN OR LOCATION OF DEATH Grand Island, Nebraska 8d. INSIDE CITY LIMITS YesI No[❑1 Be. COUNTY OF DEATH 28c. PRONOUNCED DEAO (Mo.. Day, Yr.) 9a. RESIDENCE - STATE Nebraska 9b. COUNTY Hall 9c. CITY, TOWN OR LOCATION Grand Island 9d. STREET ANO NUMBER /Including Zip Code) 1815 W Louise 68803 9e. INSIDE CITY LIMITS Yes No 30.b WAS CONSENT GRANTED? YES j NO 10. RACE - (e.g., White. Black. American Indian. etc.) (Specify) White 11. ANCESTRY (e.g.. (taken. Mexican. German, etc) ISpecily) American 12. ra MARRIED ❑ WIDOWED ❑ NEVER (�l DIVORCED MARRIED L' 13. NAME OF SPOUSE (/( w, /e. give maiden name) Pollyanne Hare 14a. USUAL OCCUPATION /Give kind of work done during most r,j of working life, even if retired! = Jeweler 14b. KIND OF BUSINESS INDUSTRY Certified Gemologist 15. EDUCATION (Specify only highest grade completed) Elemenla or Secondary 10.12) Colle (1 - or 5'I " 12 4 16. FATHER • NAME FIRST MIDDLE LAST EA '4 Robert August Meyer oil 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Catherine Hackman • 18. WAS DECEASED EVER IN U.S. ARMED FORCES? - (Yes. no. or unk.( (If yes. give war and dates of services) W Yes: W 7/16/1942 2/24/1946 19a. INFORMANT - NAME Pollyanne Meyer 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 1815 West Louise, Grand Island, Nebraska 68803 20. EMBALMER • SIGNATURE & LICENSE NO. Not Embalmed 21a. METHOD OF DISPOSITION ❑ Burial ❑ Removal 21b. DATE pril • 10, 2003 21c. CEMETERY OR CREMATORY NAME Central NE Cremation Servic 22a. FUNERAL HOME - NAME Apfel - Butler- Geddes 0 Cremation ❑Donation 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Gibbon, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY 09 TOWN. STATE, ZIP) 1123 West Second Street Grand Island", Nebraska 68803 DUE TO, OR AS A CONSEQUENCE OF: - (c) Interval between onset and death OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART II PART III IF FEMALE, WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? (Ages 10 -54) Yes ■ No 24 AUTOPSY Yes No �r 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? � Yes NO -. 26a. 1 Accident 1111 Undetermined II Suicide • Pending II Homicide Investigation 265. DATE OF INJURY /MO.. Day. Yr.) 26c. HOUR OF INJURY M 26d. DESCRIBE HOW IN,;JRY OCCURRED 26e. INJURY AT WORK ❑. ❑ Yes No 261. PLACE Q F INJURY - ppt home, farm. street factory of ice bwldin etc. ( Speciy/ 26g, LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE To be Completed by Attending PHYSICIAN ONLY 27a. DATE OF DEATH (Mo... Day. Yr.) April 9, 2003 To be Completed by CORONERS PHYSICIAN a COUNTY ATTORNEY ONLY 28a. DATE SIGNED (Mo.. Day. Yr/ 26b. TIME OF DEATH M 27b. DATE SIGNED (Mo.. Day. Yr.( April 10, 2003 27c. TIME OF DEATH 17:50 M 28c. PRONOUNCED DEAO (Mo.. Day, Yr.) 28d. PRONOUNCED DEAD (Hour( M 27d. To the best of my knowledge. death occurred at ihk tin6e date and place a due to the 0 cause(s) stated. � . (Signature and Title) • / 28e. On the basis of examination anchor investigation, in my opinion death occurred at the time, date and place and due to the causes stated. , (Signature and Title) • 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? IX I YES NO ❑ UNKNOWN r 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ,.....K , NO 30.b WAS CONSENT GRANTED? YES j NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Print, Dr. Gordon J. Hrnicek, 729 Nor h Custer, Gr nd Island, Nebraska 68803 32a. REGISTRAR / A 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) APR 1 5 2003 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN- SERVICES SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. = A; DATE OF ISSUANCE 4/16/2003 20140583 AS TAN TATEREG LINCOLN, NEBRASKA HEALTH AND -HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE --AND SUPPORT 03 04135 VITAL STATISTICS = CERTIFICATE 1 PART (al (5) DUE TO, OR AS A CONSEQUENCE OF LINE FOR Ial. (b). AND (c)) Interval between onset and death e • U V Interval between onset and eaC to