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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT OF HEALTH,
<br />IT CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR
<br />VITAL RECORDS. = -
<br />DATE OF ISSUANCE
<br />OCT 13 1995
<br />LINCOLN, NEBRASKA
<br />20190011
<br />15 = A7i COOPER
<br />A&IS'f,4IV Sl _ REGISTRAR
<br />NARASBA tRTMENT PFHEALTH
<br />STATE OF NEBRASKA — DEPARTMENT OF HEAL -1i
<br />BUREAU OF VITAL STATISTICS = =_
<br />CERTIFICATE
<br />16 FATHER . NAME
<br />Sales
<br />FIRST
<br />Hardware
<br />MIDDLE
<br />LAST
<br />17 MOTHER
<br />FIRST
<br />0cec',11 only highest grade completed)
<br />Elementary or Secondary i0 121
<br />i 10th Grade
<br />MIDL 9
<br />College 11 a o,
<br />MAIDEN SURNAME
<br />Edward NMI Meyer (Dec.) Anna NMI Somerfeld (Dec.)
<br />18 WAS DECEASED EVER IN U S. ARMED FORCES,
<br />19a. INFORMANT NAME
<br />(Yes no or unk I III yes give war and dales of services)
<br />No I N/A
<br />196 INFORMANT MAILING ADDRESS
<br />Margaret Meyer
<br />I STREET OR RFD NO. CITY OR TOWN STATE ZIP)
<br />408 N. White, Grand Island, Nebraska 68803
<br />20 tSBEL,LMER - SIGNATU ENSE NO
<br />� 21a METHOD OF DISPOSITION 21b DATE
<br />U l ME -NA
<br />Kleine Funeral Home
<br />225 FUNERAL HOME ADDRESS (STREET OR R.F.D NO CITY OR TOWN STATE. ZIP)
<br />21c CEME'ERY DR CREMATORY NAME
<br />ki Burial Removal Sept. 26, 19951 Westlawn Memorial Park
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />❑ Crernaborl Donator
<br />Grand Islanth Nebraska
<br />3213 W. North Front St., Grand Island, Nebraska 68803
<br />IMMEDIATE CAUSE /ENTER ONLY ONE CAUSE PER LINE FOR lar Ibl. AND Icp
<br />Interval between onset and aeath
<br />F APART
<br />n lal
<br />DUE TO, ORAS A CONUENCE OF
<br />lb)
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />ICI
<br />Interval
<br />een onset and deaf
<br />PART OTHER SIGNIFICANT CONDI IONS - Conditions contnOukrg to the death but not )area PART III IF FEMALE. WAS THERE AAUTOPS
<br />(�•PREGNANCY IN THE PAST 3 MONTHS' lk
<br />•
<br />ti—ej / ji r , f 51P
<br />)) (Ages 10-54) Yes ❑ No FT Yes
<br />b DATE O INJURY IMc.. Day. Ye) 26c HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED
<br />26a
<br />ElAccident
<br />ESuicide
<br />EHomlc, le
<br />0
<br />8 F
<br />Undetermined
<br />Investigalion
<br />26e INJURY AT WORK 1261 PLACE OF INJURY - At Borne. farm street factory
<br />olhce bwldirg. etc /Specrry)
<br />Yes ❑ No ❑
<br />kDATE OF DEATH rMo. Day. Yr/
<br />Interval between onset and dealt.
<br />2 WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER^
<br />Yes
<br />No
<br />26g LOCATION
<br />STREET OR F c = NO
<br />CITY OR TOWN STATE
<br />September 23, 1995
<br />ADATE SIGNED !Mo Day Yel f.t TIME OF DEATH
<br />October 3, 1995 10:25 pM
<br />1)411 To the best of my knowledge death
<br />causelsi staled — .1
<br />Signature and Title) 11
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH'
<br />❑ YES ❑ NO ® UNKNOWN
<br />occurred a time dale and place and due to the
<br />ee �tiL� T r1
<br />28a DATE SIGNED rhe. Day v; 128b TIME OF DEATH
<br />28c PRONOUNCED DEAD My Day yr
<br />8d. PRONOUNCED DEAD /How
<br />28e On the basis of exa.mnlatioe and or mvesypar.,n in my opinion death occurred al
<br />the timedate and place and cue to the :a.•Se s, slated.
<br />ISignature and Tree, 11,
<br />rd HAS ORGAN OR TIS❑SUvDONATION ES ®N COONSIDERED' i 4WAS C9WSENT
<br />❑ GRANTED rv. NO
<br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, ,Type a, Pimm YESVe'
<br />B.D. Urbauer, M.D. 2444 W. Faidley Gran stand, NE 68803
<br />32a REGISTRAR
<br />32t DATE FILED BY REGISTRAR /A Day Yr)
<br />OCL 51995
<br />1. DECEDENT - NAME
<br />FIRST MIDDLE LAST
<br />Herbert A. Meyer
<br />4 CITY AND STATE OF BIRTH
<br />2. -SEX.-- '
<br />Male
<br />3 DATE OF DEATH ;Monro Dat Year!
<br />September 23,
<br />rn nor n USA name country;
<br />5a AGE Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />1995
<br />6 DATE OF BIRTH Month Dat fear/
<br />Blue Hill, Nebraska
<br />7 SOCIAL
<br />(Yrs
<br />77
<br />5b MOS DAYS
<br />Sc.HOURS MINS
<br />June 17, 1918
<br />SECURTIY NUMBER
<br />508-14-1049
<br />8a PLACE OF DEATH
<br />HOSPITAL Inpatient OTHER
<br />I-1
<br />I I Nursing Homy
<br />LJ
<br />80 FACILITYName llf not insoNaon. give street and number)
<br />St _ Francis Skilled Care
<br />Sc CITY TOWN
<br />❑ ER Outpatient ❑ Residence
<br />❑ DOP aher,l ,, Ski 1 led Care
<br />OR LOCATION OF DEATH
<br />Grand Island
<br />9a RESIDENCE - STATE 1
<br />, 8d INSIDE CITY LIMITS
<br />, Yes E] No ❑
<br />Be COUNTY OF DEATH
<br />Hall County
<br />9b COUNTY
<br />Nebraska I Hall
<br />10 RACE leg.. White Black American Indian
<br />Sc CITY TOWN OR LOCATION
<br />Grand Island
<br />90 STREET AND NUMBER m_ ,ding Zip Code! 1 9e INSIDE CITY LIMITS
<br />408 N. White 68803 Yes No ❑
<br />111 ANCESTRY e g Italian Mexican. German. etc
<br />etc.I ISCtecily) ISpeulyl
<br />White German
<br />14a USUAL OCCUPATION
<br />12
<br />MARRIED WIDOWED
<br />NEVER DIVORCED
<br />MARRIED
<br />1
<br />13 NAME OF SPOUSE d/wde Vole maraen namer
<br />Margaret Burkhardt
<br />,Give kind of work none Ourng mast 14b KIND OF BUSINESS INDUSTRY
<br />16 FATHER . NAME
<br />Sales
<br />FIRST
<br />Hardware
<br />MIDDLE
<br />LAST
<br />17 MOTHER
<br />FIRST
<br />0cec',11 only highest grade completed)
<br />Elementary or Secondary i0 121
<br />i 10th Grade
<br />MIDL 9
<br />College 11 a o,
<br />MAIDEN SURNAME
<br />Edward NMI Meyer (Dec.) Anna NMI Somerfeld (Dec.)
<br />18 WAS DECEASED EVER IN U S. ARMED FORCES,
<br />19a. INFORMANT NAME
<br />(Yes no or unk I III yes give war and dales of services)
<br />No I N/A
<br />196 INFORMANT MAILING ADDRESS
<br />Margaret Meyer
<br />I STREET OR RFD NO. CITY OR TOWN STATE ZIP)
<br />408 N. White, Grand Island, Nebraska 68803
<br />20 tSBEL,LMER - SIGNATU ENSE NO
<br />� 21a METHOD OF DISPOSITION 21b DATE
<br />U l ME -NA
<br />Kleine Funeral Home
<br />225 FUNERAL HOME ADDRESS (STREET OR R.F.D NO CITY OR TOWN STATE. ZIP)
<br />21c CEME'ERY DR CREMATORY NAME
<br />ki Burial Removal Sept. 26, 19951 Westlawn Memorial Park
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />❑ Crernaborl Donator
<br />Grand Islanth Nebraska
<br />3213 W. North Front St., Grand Island, Nebraska 68803
<br />IMMEDIATE CAUSE /ENTER ONLY ONE CAUSE PER LINE FOR lar Ibl. AND Icp
<br />Interval between onset and aeath
<br />F APART
<br />n lal
<br />DUE TO, ORAS A CONUENCE OF
<br />lb)
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />ICI
<br />Interval
<br />een onset and deaf
<br />PART OTHER SIGNIFICANT CONDI IONS - Conditions contnOukrg to the death but not )area PART III IF FEMALE. WAS THERE AAUTOPS
<br />(�•PREGNANCY IN THE PAST 3 MONTHS' lk
<br />•
<br />ti—ej / ji r , f 51P
<br />)) (Ages 10-54) Yes ❑ No FT Yes
<br />b DATE O INJURY IMc.. Day. Ye) 26c HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED
<br />26a
<br />ElAccident
<br />ESuicide
<br />EHomlc, le
<br />0
<br />8 F
<br />Undetermined
<br />Investigalion
<br />26e INJURY AT WORK 1261 PLACE OF INJURY - At Borne. farm street factory
<br />olhce bwldirg. etc /Specrry)
<br />Yes ❑ No ❑
<br />kDATE OF DEATH rMo. Day. Yr/
<br />Interval between onset and dealt.
<br />2 WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER^
<br />Yes
<br />No
<br />26g LOCATION
<br />STREET OR F c = NO
<br />CITY OR TOWN STATE
<br />September 23, 1995
<br />ADATE SIGNED !Mo Day Yel f.t TIME OF DEATH
<br />October 3, 1995 10:25 pM
<br />1)411 To the best of my knowledge death
<br />causelsi staled — .1
<br />Signature and Title) 11
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH'
<br />❑ YES ❑ NO ® UNKNOWN
<br />occurred a time dale and place and due to the
<br />ee �tiL� T r1
<br />28a DATE SIGNED rhe. Day v; 128b TIME OF DEATH
<br />28c PRONOUNCED DEAD My Day yr
<br />8d. PRONOUNCED DEAD /How
<br />28e On the basis of exa.mnlatioe and or mvesypar.,n in my opinion death occurred al
<br />the timedate and place and cue to the :a.•Se s, slated.
<br />ISignature and Tree, 11,
<br />rd HAS ORGAN OR TIS❑SUvDONATION ES ®N COONSIDERED' i 4WAS C9WSENT
<br />❑ GRANTED rv. NO
<br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, ,Type a, Pimm YESVe'
<br />B.D. Urbauer, M.D. 2444 W. Faidley Gran stand, NE 68803
<br />32a REGISTRAR
<br />32t DATE FILED BY REGISTRAR /A Day Yr)
<br />OCL 51995
<br />
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