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To be completed by: CERTIFIER I I To be completed /verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Francis J Meister 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) September 9 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Greeley, Nebraska 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) 87 MOS. DAYS HOURS MINS. March 1, 1928 7. SOCIAL SECURITY NUMBER 723 -03 -0596 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ® Other (Specify)4SSISTED LIVING 8b. FACILITY -NAME (If not Institution, give street and number) Bickford of Grand Island 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2663 St. Patrick Ave 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ rilvorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Lois Ann Johnson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Peter J Meister 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Agnes Nealon 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 11/06/1951- 08/05/1953 14a. INFORMANT -NAME Lois Ann Meister 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Gwen K. Hyronemus 16b. LICENSE NO. 1448 16c. DATE (Mo., Day, Yr.) September 12, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final al Acute Myocardial Infarction Immediately disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Diffuse Vascular Disease 1 Chronic I any, leading to the cause listed 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death I Enter the UNDERLYING CAUSE c ) I (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST 1 d) 1 1 B. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Ischemic Cardiomyopathy with Congestive Heart Failure 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO D. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ID NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) September 9, 2015 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) September 15, 2015 23c. TIME OF DEATH 11:27 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature nd Title) Richard Fruehling, MD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE 1 6 - �- w _ �"� v 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I September 21, 2015 STATE OF NEBRASKA 201507142 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT ,i�/ T OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,fi 4 £ (T _ STANLEY S. COOPER ASSISTANT STATE REGL TRAR DEPARTMENT OF HEALTH A4D HUMAN SERVICES 1 %,' DATE OF ISSUANCE 09/22/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 15 05457