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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11/30/2018
<br />LINCOLN, NEBRASKA
<br />201900498
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />William Joseph Meister
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 2, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.),
<br />Greeley County, Nebraska
<br />(Yrs.)
<br />87
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 7, 1924
<br />7. SOCIAL SECURITY NUMBER
<br />520-32-0624
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Grano Island Veterans Home`
<br />0 ER/Outpatient 0 Decedent's Home
<br />0• ccA 0 ':.:til
<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 />1004 W. 11th St.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Esther Rose Smollen
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Peter Meister
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mary Nealon
<br />13. EVER IN U.S. ARMED FORCES? Give
<br />(Yes, No, or Unk.) Yes 06/20/
<br />dates of service if Yes.
<br />946-05/04/1947
<br />14a. INFORMANT -NAME
<br />Sally Rose Meister
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />16b. LICENSE NO.
<br />1411
<br />16c. DATE (Mo., Day, Yr.}
<br />May 6, 2011
<br />0 Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City 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 />16. 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,
<br />APPROXIMATE INTERVAL;.
<br />respiratory arreat, or ventrlyular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />!MMEDIATE CAUSE lc:^+: a) A lzhe)rnerg n.r.M.n!i..
<br />disease or condition resulting
<br />onset to death
<br />> 1 Y9'r
<br />18 death)
<br />Sequentially
<br />any, leading
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Ilat =ragtime, if b)
<br />to the cause listed'
<br />onset to death 'r
<br />on linea.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting in deem) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Carcinoma Of Prostate; Coronary Artery Disease.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 1E NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑death
<br />Pregnant at time of d
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />0
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ® NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />El ❑
<br />Suicide Could not be determined
<br />0 ❑
<br />0 Pedestrian
<br />❑Ocher (Specify)
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 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 />DYES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH /Mo.. Clay. Yr.1
<br />Mav 2 2011
<br />g Z
<br />2-`e. r 77- S2,._ (1?.:::., _-:, V.4
<br />--.-. •..-.E OF 1..Zv:e
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />May 3,2011
<br />23c. TIME OF DEATH
<br />02:05 PM
<br />Y -0 r
<br />Si
<br />eya
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Gene L. Wyse, DO
<br />' w z O
<br />g o p
<br />c K 8
<br />~ 8 8
<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 />0 YES ®NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26a.
<br />❑ YES ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Wyse, DO, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE S. `�� �__
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 9, 2011
<br />
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