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STATE r .. is ,, ATE OF NEBRASKA , $7 ..,1 ,.. ;mot WHEN THIS ;' <COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS • DATE OF ISSUANCE 8/22/2016 LINCOLN, NEBRASKA 2016(156S1 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Edwin Earl Meier 4 CITY>AND STATE. OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH DOniphan, Nebraska 7. SOCIAL SECURITY NUMBER 505.48 -6947 84. FACILITY -NAME (If not institution, give street and number) ox 13 ti CHI Health St. Francis re 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 688 a 9a. RESIDENCE -STATE Nebraska LL 9d. STREET AND NUMBER >, 2003 Bass Road 5. METHOD OF DISPOSITION E Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal • ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska DUE TO OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) ( (Disease or injury that initiated the events rea Mai rt g m death) LAST ❑ Not pregnant, but pregnant within 42 days of death. ❑ Not pregnant, but pregnant. 43 days to 1 year before death I ❑ Unknown if pregnant Within the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 It 22d. INJURY AT WORKS? 22e. DESCRIBE HOW INJURY OCCURRED r []YES ❑NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. n • p. w Q z 2Jb. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH August 17, 2016 08:26 PM • a 0 3d. To the best of my knowledge, death occurred at the time, date and place $� and due to the cause(s) stated. (Signature and Title) Dron Gauchan, MD 23a. DATE OF 'DEATH (Mo., Day, Yr.) Julr 26.2016 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES t3 NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) CITY/TOWN 84 28a, REGrSTRAR'S SIGNATURE •- 5b UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES J NO 2. SEX Male Sc. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) July 26, 2016 a, PART I. Enter die chain of events- - diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory artist or Ventrittllar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Iine,Add additional lines it necessary. IMMEDIATE CAUSE: MMEO(ATE CAUSE (Final a) Colon Cancer Metastasis Lungs And Liver disease or condition resulting APPROXIMATE NTERVAL onset to death 1 Year 6. DATE OF BIRTH (Mo., ':Day, Yr.) April 26, 1932'? ❑ Hospice Facility 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island' 8d. COUNTY OF DEATH Hall 9e. APT. NO. 19f. ZIP CODE ! I 68801 1 9g. INSIDE CITY LIMITS ® YES ❑ NO - 10a. MARITAL STATUS AT TIME OF DEATH I] Married ❑ Never Married W ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Shirley Treat Middle, Last, Suffix) If wife, give maiden name .: • 11. FATHER'S - NAME ( Flrst, Middle, Last, Suffix) d Henry Meier a 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT -NAME (Yes, No, or Ut k,) Yes 11/1952-10/1954 Shirley Meier 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anna Pape 14b. RELATIONSHIP TO DECEDENT Wife 16a. EMBALMER - SIGNATURE Katie M. Smvdra 16b. LICENSE NO. 1454 16c. DATE (Mo., Pays Yr.) July 31, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Cedarview Cemetery CITY / TOWN Doniphan STATE Nebraska i 17b. Zip Code '. 68801 CAUSE OF DEATH (See instructions and examples) In death) Sequentially list conditions, rt b) any, leading to the cause listed on line ' - DUE TO, OR AS A CONSEQUENCE OF: onset to death • onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO '. • 20. IF FEMALE: K ❑ Not pregnant: within past year ▪ ❑ Pregnant at time of death 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ? ❑ Driver /Operator ❑ Passenger 0 Pedestrian 0 Other. (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ?:. ❑YES 0 N I 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) STATE ZIP CODE' 24b. TIME OF DEATH 24d. TIME PRONOU ED DEAD 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ jf 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Dron Gauchhan, MD, 2621 W Faidley Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (MO „'Day, Yr.) August 17, 2016 STANLEY S. DOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES w Cn