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To be completed by: CERTIFIER To be completedlverified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Mervin Robert Moeller
<br />2. SEX , "
<br />Male
<br />3. DAT @OF DEATH (Mo., Day, Yr.)
<br />-' NovEm e 2 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ashton, Nebraska
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />90
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />September 24, 1920
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />558 -24 -9292
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />8b. FACILITY-NAME (H not Institution, give street and number)
<br />Grand Island Veterans Home
<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 />1812 N. Broadwell Ave.
<br />e. APT. NO.
<br />r
<br />9f. ZIP CODE
<br />I 9f 68803 I
<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 />Frances Elaine Enzminger
<br />1 1. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Moeller
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Agnes Ann Harvey
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 08/19/1942 - 04/15/1946
<br />14a. INFORMANT -NAME
<br />Frances Moeller
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER-SIGNATURE
<br />Matthew T. Myers
<br />18b. LICENSE NO.
<br />1411
<br />16c. DATE (Mo., Day, Yr.)
<br />November 5, 2010
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING 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 terminal events such as cardiac arrest, 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) Pneumonia One Week
<br />inseams or condition resulting
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, if b) Vascular Dementia > 1 Year
<br />any, leading to the cause listed
<br />on One a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or Injury that Initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST d)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART!.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 131 NO
<br />0. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ P regnant 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 />❑ Acc i dent ❑ Pestl 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 ® 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 />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />I 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 2, 2010
<br />s 124a. DATE SIGNED (Mo.. Day. Yr.)
<br />k W
<br />24b. TIME of DEATI!
<br />LL
<br />Y 23b. DATE SIGNED (Mo., Day, Yr.)
<br />E Is Z November 4, 2010
<br />23c. TIME OF DEATH
<br />01:30 AM
<br />I E p
<br />E y Y < o
<br />$ w z
<br />8 p
<br />~ 0 .5
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />8 0 �d. To the best or my knowledge, death occurred at the time, date and plea
<br />.8 c and due to the cause(s) stated. (Signature and Title)
<br />o 2 Gene L. Wyse, DO
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE
<br />❑ YES
<br />DONATION
<br />®NO
<br />BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,
<br />Gene L. Wyse, DO, 2300 West Capital Avenue,
<br />HYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY)
<br />Grand Island, Nebraska, 68803
<br />(Type or Print)
<br />I 28a. REGISTRAR'S SIGNATURE /)1 /► -
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 4, 2010
<br />l
<br />DATE OF ISSUANCE
<br />11/09/2010
<br />LINCOLN, NEBRASKA
<br />STATE
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A� VFJ1 JiM*N f if R VVCE4S, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE8RA
<br />,
<br />aff4PIANCIF Olf ( -AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR WTAL \ 42EC0 D5 `
<br />E %
<br />, +� .
<br />2018
<br />STANLEY S. c Q,PER �
<br />ASSISSTAN E: E GIST RAR ."
<br />DEPARrtME 13EAL'rI f ANA•
<br />HUMAN SERVICES ,,-
<br />OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES .. i ;* 10 03148
<br />CERTIFICATE OF DEATH ( i ''T -�
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