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<br />7. SOCIAL. SECURITY NUMBER
<br />9f. ZIP CODE
<br />St. PLACE OF DEATH
<br />d
<br />506-26-9415
<br />I 68803
<br />HOSPITAL ❑ Inpatient
<br />OTHER ® Nursing Home/LTC ❑ Hospice Facility
<br />a
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />[] ER/Outpatient
<br />❑ Decedent's Home
<br />rm
<br />Good Samaritan Sbciety-Grand Island Village
<br />❑ 60A
<br />❑ Other (Specify)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Frank Urbanek Clara Razim
<br />ad. COUNTY OF DEATH
<br />t4
<br />Grand Island 68803
<br />14a. INFORMANT -NAME
<br />Hall
<br />9a. RESID€NCE$TATE
<br />9b. COUNTY
<br />Lar Meyer
<br />Se. CITY OR TOWN
<br />Nebraska
<br />Hall
<br />18b. LICENSE NO.
<br />Grand Island
<br />e `
<br />9d. STREET AND NUMBERAPT. NO.
<br />9f. ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />m
<br />3990 West Capital Avenue r,
<br />I 68803
<br />1 ® YES ❑ NO
<br />y
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />©:Married, but separated ® Widowed ❑ Divorced ❑ Unknown
<br />Everett Meyer
<br />Ib
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHERS -NAME (First, Middle, Maiden Surname)
<br />m
<br />Frank Urbanek Clara Razim
<br />�+
<br />13. EVER IN U.& ARMED FORCES? Give dates of serviceif Yes.
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, No, or Unk.) NO :
<br />Lar Meyer
<br />Son
<br />15. METHOD OF DISPOSITION
<br />18a. EMBALMER -SIGNATURE
<br />18b. LICENSE NO.
<br />1So. DATE (Mo., Day, Yr.}
<br />®`Burial Q Donation
<br />Gwen K. Hyronemus
<br />1448
<br />January 18, 2020
<br />❑ Cremation ❑ Entombment
<br />15d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />V_
<br />7
<br />❑ Removal (J Other (Speclty)
<br />u
<br />Mt. Pleasant Cemetery Cairo Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />17b, Zjp Code
<br />o
<br />Aofel Funeral Home, 1123 W. 2nd, Grand Island. Nebraska
<br />68601
<br />v
<br />{
<br />CAUSE OF DEATH (See Instructionsn ex
<br />ie. PART I. Enter tim chaln of avems• diseases, Injuries, or complications -that directly caused the deem. DO NOT enter t@ ' I events such as cardiac arrest, APPROXIMATES INTERVAI,.
<br />feepiratory arrest, or W noli ular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a )IIIc- Add additional lines H necessary..
<br />IMMEDIATE CAUSE: onset to death
<br />w
<br />IMMEDIATE CAUSE (Final 8) Hypertension 15 Years
<br />diseasa or condition resulting
<br />in clogthi
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death"
<br />sequentially It" ations,n!>b)Cerebral Vascular Accident 3Weeks
<br />any, feadhIf to #0 cause l4ted
<br />0
<br />d
<br />on inrie a. DUE TO, OR AS A CONSEQUENCE OF: ; on at to death
<br />.0
<br />Enter the UNDERLYING CAUSE C) i
<br />p
<br />tdisesea er injury that initiated: '
<br />nnts'"Pr" dara') to ! > DUE TO, OR AS A CONSEQUENCE OF: onset death
<br />LAbTM
<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 />19. WAS MEDICAL EXAMINER
<br />Ischemic Heart Disease, Hypercholesterolemia
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF?FEMALE : '
<br />21e. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?'
<br />t
<br />❑ Not pregnant wain past year
<br />® Natural ❑ Homicide
<br />© Driver/Operator
<br />❑ YES ® NO
<br />❑ Pregnant at time of death
<br />❑ Accident ❑ Pending Investigation
<br />❑ Passenger
<br />❑ NGJLLpngn&K but Pregnant within 42 days of death
<br />❑ Suicide Could not determined
<br />© Pedestrian
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE:
<br />© Not pregnant; but prapdanl I3 days to 1 year beton death
<br />Q Other.(Specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ Unknown H p egnard within the past year
<br />❑ YES ❑ NO
<br />,2
<br />22s. 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 />a
<br />9
<br />22d. INJURY ATWORK?
<br />229. DESCRIBE HOW INJURY OCCURRED
<br />AYES ❑ NQ
<br />LOCATION OF INJURY - STREET a NUMBER APT.NO. CITY/TOWN
<br />N
<br />a
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />Janu
<br />AN 14, 2020 _
<br />23b. GATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />g
<br />January 1 4:42 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />oand due to the cause(s) sated. (Signature and Tile))
<br />William Landis, MD
<br />b'
<br />25.010 TOSACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS C
<br />❑ YES ® NO Q PROBABLY ❑ UNKNOWN ❑ YES
<br />27. NAME, TITLE AND ADDRE 0 C RTIFIER (Type or Print)
<br />William Landis, MD, 2444 W. Faidley Avenue, Grand Isla
<br />?Ba. REGISTRAf;'S SIGNATURE
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNC D DEAD
<br />34s. On tie basis of examination and/or Investigation, M my opinion deem occurred at
<br />ro. W... d.r...d .1- e.d d.,. to th. e.uulei .feted_ rabnarere and Tid.t r
<br />
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