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