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To be completed by: CERTIFIER I I To be completed/verified by: FUNERAL DIRECTOR '
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Melvin Walter Meyer
<br />2;4011; l r ?
<br />Wig ` {
<br />DA (Mo., Day, Yr.)
<br />; Q b 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Palmer, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />88
<br />5b. UNDER 1 YEAR
<br />Sc. UNDEtPd'4;
<br />‘ 6,,,:94,,T$ OF BIRTH (Mo., Day, Yr.)
<br />December 11, 1926
<br />MOS.
<br />DAYS
<br />HOURS
<br />, MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -48 -5521
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA tfo her (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d, COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />404 Woodland Drive
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />I 68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />JoAnn Sigman
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Herman Meyer
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Helen Leuthaeuser
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 12/07/1950 - 09/19/1956
<br />14a. INFORMANT -NAME
<br />JoAnn Meyer
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />1071
<br />16c. DATE (Mo., Day, Yr.)
<br />October 29, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events-diseases, injuries, or complications -that directly caused the death. DO NOT enter tenninal events such as cardiac arrest, r APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final a) Clostridium Difficile Colitis Days
<br />disease or condition resulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />Sequentially list conditions, if b) I
<br />any, leading to the cause listed I
<br />on line a: DUE TO, OR AS A CONSE(UENCE OF: : onset to death
<br />Enter the UNDERLYING CAUSE C) 1
<br />(disease or injury that initiated -
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LAST d) 1
<br />1
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Respiratory Arrest, Immunosuppression, Dehydration, Atrial Fibrillation,
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES El NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time 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 past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />DYES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />123a. DATE OF DEATH (Mo., Day, Yr.)
<br />1 W October 25, 2015
<br />7 > 1
<br />Q r,
<br />° s ue
<br />; a
<br />u W z
<br />C U
<br />e s
<br />12
<br />a
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />1 67 P r 23b. DATE SIGNED (Mo., Day, Yr.)
<br />I u i October 28 201 S
<br />23c. TIME OF DEATH
<br />07:37 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />I O 3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Si and Title)
<br />0 o Travis S. Hageman, MD
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />I the time, dare and place and due to the cause(s) sated. (Signature and n tIs)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />r
<br />128a REGISTRAR'S SIGNATURE
<br />I
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 2, 2015
<br />DATE OF ISSUANCE
<br />11/05/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />��'�A.
<br />201508719
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIZACRIZ` R ;,
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S E VJCES • r'9� / 06329
<br />• CERTIFICATE OF DEATH r :' •' ;? �'
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