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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 />1/24/2020
<br />LINCOLN, NEBRASKA
<br />202001408 RUSSELL FOSLER
<br />(� ASSISTANT STATE REGISTRAR
<br />F" 0 2 0 0 1"a 0 9 D AND HUMAN SERVICES
<br />EPARTMENT OF H
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Dorothy Mae Meyer
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ravenna, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-26-9415
<br />Ba. AGE - Last Birthday
<br />(Yrs.)
<br />94
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Sb. UNDER 1 YEAR
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />[] ER/Outpatient
<br />0 DOA
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />HOURS MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 14, 2020
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />August 9, 1925"
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMB£it
<br />3990 West Capital Avenue
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY £UNITS'
<br />® YES ❑ NO
<br />lea. MARITAL STATUS AT TIME OF DEATH 0 Marded ❑ Never Married
<br />©;Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Frank Urbanek
<br />10b. NAME OF SPOUSE (First,
<br />Everett Meyer
<br />Middle, Last, Suffix) If wife, give maiden name
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Clara Razim
<br />13. EVER IN U.S..ARMED;FORCES? Give dates of service if Yes.
<br />(Yee, N0, or Utk.) No
<br />15. METHOD OF DISPOSITION
<br />®'Burial 13 Donation
<br />❑ Cremation 0 Entombment
<br />Q Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Larry Meyer
<br />18a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />18b. LICENSE NO.
<br />1448
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo., Day, Yr.)
<br />January 18, 2020
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Mt. Pleasant Cemetery
<br />17a. FUNERALHOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home, 1123 W. 2nd. Grand Island. Nebraska
<br />CITY / TOWN
<br />Cairo
<br />CAUSE OF DEATH (See Instructions and examolesl
<br />I. PART I. Enter the Chain of events- -diseases, Injuries, or complicatons4hat directly caused the Wath. DO NOT enter terminal events such as cardiac arrest,
<br />rbpiratery artier., at Ventricular fllMlletion without showing the etiology. DO NOT ASSAUVIATE. Enter only one ause-:en •• IfM Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Hypertension
<br />camase or condition resusing
<br />y in (seta)
<br />ie aepuentialy list conditiau. If
<br />any, lesdingtothiciu$a hated
<br />.0 on lir* I.
<br />ea
<br />STATE
<br />Nebraska
<br />17b. Zip code
<br />68801
<br />APPROXIMATE I
<br />onset to death
<br />15 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Cerebral Vascular Accident
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />« Enter the UNDERLYING CAUSE c)
<br />`S (disease or Injury filet initiated
<br />ev!ents resulting In Wath);,:
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />m
<br />« 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART L
<br />t
<br />IP
<br />E
<br />U
<br />u
<br />w
<br />Ischemic Heart Disease, Hypercholesterolemia
<br />20. IF FEMALE:
<br />0 Not pregnant within pest year
<br />Pregnant at time of death
<br />Net pregnant; but pregnant within 42 days of. death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />a 122a. DATE OF INJURY (Mo., Day, Yr.)
<br />9
<br />22d. INJURY AT WORK?
<br />AYES ONO
<br />21a. MANNER OF DEATH
<br />▪ Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not ha determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />Othar.(Specify)
<br />onset to death
<br />3 Weeks
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<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 />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />a • 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />`c 234. DATE OF DEATH (Mo., Day, Yr.)
<br />L' January 14. 2020
<br />• ;y 23b. DATE SIGNED (Mo., Day, Yr.)
<br />CITY/TOWN
<br />o } 23c. TIME OF DEATH
<br />8 I iJanuary 21. 2020 04:42 AM
<br />23d. To the best of my knowledge, death occurred at the tee, date and place
<br />to o and due to the causal.) stated. (Signature and Title)
<br />" William Landis. MD
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ED NO 0 PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Willem Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investiyatlon, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is NO 0 YES 0 NO
<br />28aREGISTRAR`S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR(M0., Day, Yr.) I
<br />January 21, 2020
<br />
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