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<br />WHEN THIS COPY CARRIES THE RA /SED SEAL OF THE NEBRASKA STATE DEPARTMENT OF Tlsl,
<br />IT CERT IF IES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ONA" *W rr
<br />DEPARTMENT OF HEAL TH, BUREAU OF VITAL STAT IST /CS, WHICH IS THE LE"t DEPOS?Oit Y FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE 200002884
<br />JAN = =�T "6
<br />1996 Y4 ASrz s€eis
<br />LINCOLN, NEBRASKA NEBRASKW DEP/€_RTMENZ-aLTI_ .
<br />4 STATE OF NEBRASKA — DEPARTMENT GW.k1EALTl4 _
<br />BUREAU OF VITAL STATISTICS' =. _ = --
<br />CERTIFICATE OF nFATA�--
<br />F15iECEDENT -NAME FIRST MIDDLE LAST
<br />2 SEF _ _ 3 pATEOF &E�Ar',M°nIQ.Day. Year)
<br />;1j Ii
<br />1995
<br />Map�EetpAYv
<br />4. CITY AND STATE OF BIRTH rn ndfn USA as1Bn UNDER YEAR
<br />a
<br />n
<br />n
<br />Sc. HOURS MINIS
<br />SOCIAL
<br />Au ust 7, 1914
<br />O ,,r,
<br />26e INJURY AT WORK
<br />__�- —
<br />17C 487 -30 -4656 HOSPITAL O Inpa, em OTHER ❑ N—ng Home
<br />11
<br />St. Francis Medical Center ❑ DOA Ore „Spech,
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<br />i
<br />�
<br />l
<br />9a RESIDENCE - S7A7E 9b CO UNTY 9c CITYTOWN OR LOCATION
<br />REET AND NUMBER Iln('lud, rq Lp Coder W INSIDE CITY LIMITS
<br />Nebraska Hall Grand Isla23
<br />#LIE
<br />South Broadwell Yes No
<br />'_S
<br />WIDOWED 13 NAME OF SPOUSE .n wire owe maiden name)
<br />Ista —tyl
<br />White American
<br />L
<br />DIVORCED Ruby Keller
<br />14a USUAL OCCUPATION IGw krnd of wco done d, r W nest 141, KIND OF BUSINESS INDUSTRY
<br />Of wCA-1 Irk. even Aretaed)
<br />rn �Z
<br />Watchmaker Bank Lock Specialist
<br />time °ta " °`�`° �i0t21 College °”'
<br />16. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER
<br />2'
<br />FIRST' MIDDLE MAIDEN SURNAME
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<br />c .
<br />18 WAS DECEASED EVER IN U S ARMED FORCES' 119a. INFORMANT - NAME
<br />(Yes no or ur*.1 IB yes give war and dates of sewesl !
<br />'320 DATE FILED RV R -3Siq q ° pay yr)
<br />DEC o 1995
<br />Yes: 0 -7 -42 6 -30-43 WW II I Ruby Meyer
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<br />21c CEMETERY OR CREMATORY NAME
<br />®
<br />. 'FUNERAL HOME � NAM uda)
<br />22a B ❑ mo
<br />Removal . Dec. 4 1995 Westlawn Memorial Park
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes ❑ GeA1d01 1:1 D0nde0n
<br />C>
<br />22b FUNERAL
<br />o
<br />p tv
<br />1123 West Second, Grand Island, NE. 68801
<br />23 IMMEDIATE CAUSE (ENTER ONLY ONF CAI IqP PEP i OAF Pno —
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<br />�%�_
<br />WHEN THIS COPY CARRIES THE RA /SED SEAL OF THE NEBRASKA STATE DEPARTMENT OF Tlsl,
<br />IT CERT IF IES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ONA" *W rr
<br />DEPARTMENT OF HEAL TH, BUREAU OF VITAL STAT IST /CS, WHICH IS THE LE"t DEPOS?Oit Y FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE 200002884
<br />JAN = =�T "6
<br />1996 Y4 ASrz s€eis
<br />LINCOLN, NEBRASKA NEBRASKW DEP/€_RTMENZ-aLTI_ .
<br />4 STATE OF NEBRASKA — DEPARTMENT GW.k1EALTl4 _
<br />BUREAU OF VITAL STATISTICS' =. _ = --
<br />CERTIFICATE OF nFATA�--
<br />F15iECEDENT -NAME FIRST MIDDLE LAST
<br />2 SEF _ _ 3 pATEOF &E�Ar',M°nIQ.Day. Year)
<br />Aloys Gerhard Meyer
<br />Meyer
<br />1995
<br />Map�EetpAYv
<br />4. CITY AND STATE OF BIRTH rn ndfn USA as1Bn UNDER YEAR
<br />a
<br />6 DA 31 Mpnp1ry Via`
<br />lYrs 5b MOS ' DAYS
<br />St. Clement, Missouri 81
<br />Sc. HOURS MINIS
<br />SOCIAL
<br />Au ust 7, 1914
<br />SECURTIY NUMBER 8a PLACE OF DEATH
<br />26e INJURY AT WORK
<br />__�- —
<br />17C 487 -30 -4656 HOSPITAL O Inpa, em OTHER ❑ N—ng Home
<br />b FACILITY - Name /a trot mslaunorl, give sneer and number) ER Oulpabent ❑ Res,oence
<br />St. Francis Medical Center ❑ DOA Ore „Spech,
<br />8 CITY TOWN OR LOCATION OF DEATH 8c INGICE CITY LIMITS
<br />I 3e. COUNTY OF DE.4'H
<br />Grand Island Yea ® No
<br />l
<br />9a RESIDENCE - S7A7E 9b CO UNTY 9c CITYTOWN OR LOCATION
<br />REET AND NUMBER Iln('lud, rq Lp Coder W INSIDE CITY LIMITS
<br />Nebraska Hall Grand Isla23
<br />#LIE
<br />South Broadwell Yes No
<br />t0 ,RACE - leg. Wbne Black Amer¢an sWlan t t. ANCESTRY leg tlaean. Mex¢an German. etcl t2
<br />etc.l (Soecityl
<br />WIDOWED 13 NAME OF SPOUSE .n wire owe maiden name)
<br />Ista —tyl
<br />White American
<br />L
<br />DIVORCED Ruby Keller
<br />14a USUAL OCCUPATION IGw krnd of wco done d, r W nest 141, KIND OF BUSINESS INDUSTRY
<br />Of wCA-1 Irk. even Aretaed)
<br />t 5 EDUCATION (Spec -, only N hest rode com lad)
<br />9 9 pre
<br />Watchmaker Bank Lock Specialist
<br />time °ta " °`�`° �i0t21 College °”'
<br />16. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER
<br />2'
<br />FIRST' MIDDLE MAIDEN SURNAME
<br />Herman Me er
<br />Catherine B4 en
<br />18 WAS DECEASED EVER IN U S ARMED FORCES' 119a. INFORMANT - NAME
<br />(Yes no or ur*.1 IB yes give war and dates of sewesl !
<br />'320 DATE FILED RV R -3Siq q ° pay yr)
<br />DEC o 1995
<br />Yes: 0 -7 -42 6 -30-43 WW II I Ruby Meyer
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R D NO CITY OR TOWN. STATE. ZIPI
<br />623 South Broadwell, Grand Island, NE. 68803
<br />20. EMB NATUREd 21a METHOD OF DISPOSITION 21b DATE
<br />21c CEMETERY OR CREMATORY NAME
<br />®
<br />. 'FUNERAL HOME � NAM uda)
<br />22a B ❑ mo
<br />Removal . Dec. 4 1995 Westlawn Memorial Park
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes ❑ GeA1d01 1:1 D0nde0n
<br />22b FUNERAL
<br />Grand Island, Nebraska
<br />HOME ADDRESS (STREET OR R F.D. NO.. CITY OR TOWN. STATE. ZIP(
<br />1123 West Second, Grand Island, NE. 68801
<br />23 IMMEDIATE CAUSE (ENTER ONLY ONF CAI IqP PEP i OAF Pno —
<br />r InI
<br />lal
<br />DUE TO. OR AS A
<br />fbl
<br />DUE TO OR AS A
<br />cl
<br />N
<br />mre,vai cetween onset and oeatn
<br />Interval between onset and death
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<br />Inte•vaI netween on5°I and neair
<br />OTHER SIGNIFICANT CONDITIONS Condmons contributing to the death but not related
<br />PART
<br />PART III IF FEMALE WAS THERE A 2a gUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />II
<br />PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER'
<br />26a 26b DATE OF INJURY lAb. Day. Yr.J 26, HOUR OF INJURY
<br />(A as 10 -541 Yes No Ves Nc Yes No
<br />DESCRIBE HOW INJURY OCCURRED
<br />Accident � Undetermined
<br />126d.
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<br />Suicide ❑ Pending
<br />26e INJURY AT WORK
<br />26f PLLAqCE OF INJURY . At hone, farm. street. factory
<br />othce bu4 ng, etc lSpedIfY!
<br />26g LOCATION STREET OR R E D NO CITY OR TOWN STATE
<br />Homicide Investlgatan
<br />Yes No
<br />❑ ❑
<br />27a DATE OF DEATH rW Day Yr.)
<br />28a DATE SIGNED /MO Day Yr I 28b TIME OF DEATH
<br />= December 1, 1995
<br />uyyi 27b DATE SIGNED /MO Day Y,) 27C TIME OF DEATH
<br />"' 28c PRONOUNCED DEAD i44c Da Yr, r M
<br />Y 28d. PRONOUNCED DEAD /hbun
<br />'� December 5, 199 0915 M��o
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<br />270 To ifte best of my knowledge oc reo at the a to and place and aue !e the
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<br />° ° ° 28e On the hosts of exammauon and or I
<br />cause)') stated / -
<br />_
<br />,s:cr in m
<br />_ ,_ death occurred at
<br />the Irme. date and Dlace am Ca,_
<br />'Signature and TNe1 ► IS nature and TroeI b-
<br />29 DID TOBACCO USE CONTRIBUTM THE DEATH' 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED'
<br />YES ❑ NO ❑X UNKNOWN ❑
<br />YES ❑X NO ❑ YES a NO
<br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN. CORONERS PHYSICIAN OR COUNTY AT70RNEY1
<br />! type ov Pnnll
<br />Jose Nader M.D. 3016 W. Faidley Ave., Grand Island, NE. 68803
<br />32a REGISTRAR
<br />'320 DATE FILED RV R -3Siq q ° pay yr)
<br />DEC o 1995
<br />
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