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1. DECEDENT - NAME FIRST MIDDLE LAST <br />Donald Eugene . Meyer <br />e �" <br />3. ,DATEOF D EATH (Month. Day. Year) <br />February 2, 2004 <br />4. CITY AND STATE OF BIRTH /H not in U.S.A.. name country) <br />Louisville, Nebraska <br />5a. AGE - Last Birthday <br />(Yrs.) <br />82 <br />UNDER 1 YEAR' <br />, UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day. Year) <br />October 22, 1921 <br />50. MOS. J DAYS <br />5c. HOURS MINS. . <br />7. SOCIAL SECURTIY NUMBER <br />• 505-26 -0473 <br />8a. PLACE OF DEATH <br />HO r <br />❑ <br />❑ <br />.Inpatient OTHER ❑ Nursing Home <br />ER Outpatient ❑ Residence <br />DOA ❑ Other (Seemly( <br />8b. FACILITY - Name (l/ not institution, give street and number) <br />St. Francis Medical Center <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />Grand Island, Nebraska <br />18d. INSIDE CITY LIMITS <br />Yes [J No ❑ <br />8e. COUNTY OF DEATH <br />Hall <br />9a. RESIDENCE - STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Island <br />9d. STREET AND NUMBER (Including Zip Code) <br />710 Gunbarrel Rd. 68801 <br />9e. INSIDE CITY LIMITS <br />Yea ❑ No <br />10. RACE - (e.g., White. Black. American Indian. <br />etc.( (Specify) <br />White <br />11. ANCESTRY (e.g.. Italian, Mexican. German, etc) <br />(Specify) <br />German <br />12. [0 MARRIED ❑ WIDOWED <br />JJ NEVER <br />[] IT DIVORCED <br />Maa alED <br />13. NAME OF SPOUSE (0 wife. give maiden name) <br />GloriaLLaRocca <br />14a. USUAL OCCUPATION (Give kind of work done during most <br />of working fife, even it retired) <br />Owner <br />14b. KIND OF BUSINESS INDUSTRY <br />Commercial Refrigeration <br />15. EDUCATION ( Speciy only highest grade completed) <br />Elementary or Secondary I0 -121 College 11 -4 or 5 -I <br />8th Grade <br />16. FATHER - NAME FIRST MIDDLE LAST <br />George Martin Meyer <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Pearl Margaret Jardine <br />18. WAS DECEASED <br />(Yes. no. or unk.) <br />Yes <br />EVER IN U.S. ARMED FORCES? <br />Ilf yes. give war and dates of services) <br />WWII 1942 -1945 <br />19a. INFORMANT - NAME <br />Gloria Meyer <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />710 Gunbarrel Rd. P.O. Box 202 Grand Island, Nebraska 68801 <br />20. EMBALMER - SIGNATURE & LICENSE NO. <br />Not Embalmed <br />21a. METHOD OF DISPOSITION <br />❑ Burial Removal <br />p( <br />.6i Cremat Donation <br />21b. DATE <br />Feb 2, 2004 <br />21c. CEMETERY OR CREMATORY NAME <br />Westlawn Mem. Park Cremato <br />22a. FUNERAL HOME - NAME <br />Livingston - Sondermann F.H. <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />601 North 'Webb Road Grand Island, Nebraska 68803 <br />23. IMMEDIATE CAUSE \ . A A ENTER ON . LV O CAU PER LINE FOR � ONE \ la). (bb)). AND (c)) <br />T AR (1 f31 SSt f �1 `� ` N- � twr • \ 1 V N) 1...4 C V 'LC � 1 � <br />Interval between onset and death <br />y` / <br />DUE TO, OR AS A CONSEQUENCE OF <br />Interval between onset and death <br />y. <br />DUE TO, OR AS A CONSEQUENCE OF: <br />(c) <br />Interval between onset and death <br />PART OTHER SIGNIFICANT ONDITIONS - Conditions confrib ' to the death but not related , <br />II t ` ^ � {/ ` 1 \ �['� `'' t� 1 ( \ wB" 4-33 �\` <br />PART III IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />(Ag s 10-54) 54) Yes No [ <br />24 AUTOPSY <br />es Li No X. <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />^ v <br />Yes n No <br />28a. � <br />■ Accident ■ Undetermined <br />1 Suicide • Pending <br />II Homicide Investigation <br />2 OF INJURY (Mo.. Day. Yr) <br />26c. HOUR OF INJURY <br />M <br />HOW INJURY ED <br />26e. INJURY AT WORK <br />Yes ❑ No ❑ <br />281. office bupdinNJURV - ime, farm. street. factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />To be Cortpleled by <br />Abendi g PHYSICIAN <br />ONLY <br />27a. 'DATE OF DEATH (Mo.. Day. Yr) 1 <br />�. O v,. aot <br />To be Completed by <br />CORONER'S PHYSICIAN <br />or COUNTY ATTORNEY <br />ONLY <br />28a DATE SIGNED (Mo.. Day. Yr.) <br />28b. TIME OF DEATH <br />27b. DATE SIGNED (Mo.. Day. Yr.) <br />Y. O a,t V \k <br />27c. TIME OF DEATH <br />X U O J M <br />28c. PRONOUNCED DEAD (Mo.. Day, Yr.) <br />28d. PRONOUNCED DEAD. (Hour) <br />M <br />27d. To the best of my k wledge. death occ ed at the time, dnii place and d the <br />1 0, x g ausels) stated. ^ \ \ <br />(Signature and Title) �� ' \ �,, L Mo <br />28e. On the basis of examination andior investigation, in my opinion death occurred at <br />the time, date and place and due to the causes) stated. <br />(Signature and Title)' <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />X ❑ YES �� NO ❑ UNKNOWN <br />30,a HAS ORGAN OR TISSUE DONATION BEE CONSIDERED? <br />C YES I�/L NO <br />'\ <br />30.b WAS CONSENT GRANTED? �� <br />x ❑ YES / �0 <br />31. NAME AND ADDRESS OF CERTIFIER {PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY' (Type or Print) <br />_ <br />X - 3kIa. 3-t ( v\nP_ (cc 1)1 v . q1 /U C,�,�.� --er a' ✓cck.c .L lap, d. Ai 47,86'03 <br />32a. REGISTRAR ' <br />°4 r . <br />:. <br />.1 ►,i;; <br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) <br />FEB _ 3 2004 <br />DATE OF ISSUANCE <br />3/25/2004 <br />LINCOLN, NEBRASKA <br />9 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND I ll] ;SERVICES <br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF MEOW ECORD Y FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, - VITAL S`_SECT,ON,, - WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />A lys r <br />twAtrli 4ND <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH Ali? 11AN fJ I1ff iC, ' <br />VITAL STATISTICS:- a k+ <br />CERTIFICATE <br />201507730 <br />`SUPPORT <br />04 01000 <br />The North One -Half (N 1/2) of Lot Eight (8), Block One <br />Hundred Ten (110) Railroad Addition to Grand Island, Hall <br />County, Nebraska. <br />