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V9r 111461:411 t N. ,Y, yu FirX:n STATE OF NEBRASKA 1 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 201606104 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH cor STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES NWOMENO 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Edwin Earl Meier 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH L. Doniphan, Nebraska 7. SOCIAL SECURITY NUMBER 505 -48 -6947 Sb. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a RESIDENCE -$TAT Nebraska 9d. STREET AND NUMBER 2003 Bass Road 1t1d. MARfTAL STATUS AT. TIME OF DEATH E Married ❑ Never Married ❑ Married, bUt separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Henry Meier 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes ,;11/1952- 10/1954 15. METHOD OF DISPOSITION E Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other(Specify) Cedarview Cemetery 17a. FUNERAL HOME NAME` AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska 20. IF FEMALE: ❑ Not pregnantwlthin past year ❑ Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ Not pre9nant,btt pregnant 43 days to 1 year before death ❑ 41pknown if pregnant wahipthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑YES ❑NO 23a. DATE OF DEATH (Mo., Day, Yr.) J ly 26 2016 2 rc Y - 23 I w ..1. o z 0 23d. To the best of my knowled ge, death ocr.,!•retl a. the time, da!e snl place and due to the cause(s) stated. (Signature and Title) b. DATE SIGNED (Mo., Day, Yr.) August 17, 2016 Dron >Gaucllan, MD 23c. TIME OF DEATH 08:26 PM 25. DID TOBACCQ USE CONTRIBUTE TO THE DEATH? YES ENO ❑ PROBABLY ❑ UNKNOWN 28a. REGISTRAR'S SIGNATURE 6 5a, AGE - Last Birthday (Yrs.) 84 9b. COUNTY Hall 5b. UNDER 1 YEAR MOS. 16a. EMBALMER- SIGNATURE Katie M. Smydra DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑`ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hail 9c. CITY OR TOWN Grand Island 9f. ZIP CODE 68801 1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Shirley Treat 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 1 ,12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anna Pape 14a. INFORMANT -NAME Shirley Meier 16b. LICENSE NO. 1454 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Doniphan 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian Other(SpecifY) 24a. DATE SIGNED (Mo., Day, Yr.) August 17, 2016 3. DATE OF DEATH (Mo., Day, Yr.) July 26, 2016 6. DATE OF BIRTH (MO., Day, YT.} April 26, 1932 9g. INSIDE CITY LIMITS ❑ YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife • 16c. DATE (Mo., Day, Yr.) July 31, 2016 STATE Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1d. PART I. Enter the chain of events -- diseases, injuries, or complications -that directly caused the death, 00 NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. a) Colon Cancer Metastasis Lungs And Liver IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final disease or condition resulting in death) APPROXIMATEINTERVAL:: onset to death` 1 Year sequentially list equdltions, if :;: b) any, leading to the cause listed Enter the UNDERLYING CAUSE (disease Or injury that initiated the events resulting: In death) DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E YES ❑ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE Of DEATH ?: ❑ YES ❑ NO 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b, TIME OF DEATH 4.3 I 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 'a E r Z 6 .e. Cr. the basis el ccar ..a >n and/or %nv» ,galaery Frvr,ir fin dab. aceurted to O Z D the time, date and place and due to the cause(s) stated. (Signature and Tine) O 26a. HAS GROAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ENO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES, ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Dron. Gauchan, MD, 2621 W Faidley Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (MO:, Day,Yr.)