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STATE OF NEBRASKA „ie ., r -__ -« yam ,.:- - sal 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 7/22/2016 LINCOLN, NEBRASKA 201708339 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ate STANLEY S.'i000PER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Beverly Jean Meyer 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Omaha, Nebraska 7. SOCIAL SECURITY NUMBER 505 -54.- 0451. $4. FACILITY -NAME (If not Institution, give street and number) 2809 Lakewood Circe 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand island 68801 9a, RESIDENCE -STATE Nebraska • 5d. STREET AND NUMBER 2809 Lakewood Circle lea. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married 0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 1. FATHER'S -NAME (First, Middle, Last, Suffix) Marvin Niemeyer 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link.) No 16. METHOD OF DISPOSITION ❑ Burial ❑ Donation E Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 20. IF FEMALE: E Not pregnant Within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pegnant, ut pregnant 43 days to 1 year before death ❑ •Unknown if pragnantwithin past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑ YES ONO 5a. AGE Last Birthday (Yrs•) 74 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Not Embalmed 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could net be determined 1. u W .i %30 DATE. OP .DEATH (Mc. Day, Yr. Ju(Y 16.2016 Y D. z Jul 18 2016 08:55 AM 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) JanGR. McDonald, MD 25. De TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES RI NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a. REGISTRARS SIGNATURE / /]t � d _ Sb.i UNDER `1 YEAR MOS. AYS 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) July 16, 2016 6. DATE OF BIRTH (MO., Day, Yr,) July 11, 1942 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing HomeILTC ❑ ER/Outpatient E Decedent's Home 0 DOA ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall Ic. CITY OR TOWN Grand island 9e. APT. NO. 9f. ZIP CODE 68801 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Garry Eugene Meyer 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) 1 Irene Schultz 14a. INFORMANT- NAME. Garry Eugene Meyer 4613 LICENSE NO. 9g. INSIDE CITY UNITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day, Yr.) July 18, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Serv)ces CITY /TOWN Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEAJTHASee instructions and examples) 18. PARTi. Enter the strain of events diseases, injuries, or complications -that directly caused the death. DO 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. IMMEDIATE CAUSE (Final disease or condition resulting IMMEDIATE CAUSE: a) Ovarian Cancer, Metastatic APPROXIMATETNTERVAL: onset to death One Year M death) Sequentially tilt conditions, 4 any, leading tothe cause Fisted -? online DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE • fdrsease 0r injury (Hat initiated DUE TO, OR AS A CONSEQUENCE OF: C) onset to death the events resu Ling in de. LAST >( ... DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Diabetes Type 2, Autoimmune Hepatitis, Hypertension, Gastroesophageal Reflux Disease, History Of Melanoma In Situ 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian Other (specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES No 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY /TOWN STATE • ZIP CODE • 24a. DATE SIGNED !Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES ENO 1 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination andlor 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 ❑ NO 28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.) July 18, 2016