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<br />WHEN THIS G"COPY CARRIES THE RAISED SEAL QF 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 />424
<br />DATE OFISSUANCE RUSSELL FOSLER
<br />10/17/2019 202003604 ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OE HEALTH
<br />AND HUMAN SERVICES
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH'
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Thomas Henry Meuret Jr
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Burwell, Nebraska
<br />Sea AGE - Last Birthday
<br />95
<br />8b. UNDER 1 YEAR
<br />MOS. DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 8, 2019
<br />6. DATE OF BIRTH (Ma, Day, Yr,)
<br />December 16, 1923
<br />7. SOCIAL SECURITY NUMBER
<br />508-18-7400
<br />O 8b. FACILITY -NAME (11 not Institution, give street and number)
<br />Edgewood Vista Grand Island
<br />g Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />V Grand Island 68803
<br />co
<br />m
<br />x4.
<br />1
<br />t
<br />1
<br />lie
<br />wi^
<br />N
<br />RESIDENCE4TATE
<br />Nebraska !.
<br />9d. STREET AND NUMBER
<br />404 E. 14th Street
<br />8a. PLACE OF DEATH
<br />HOSPITAL _] Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedents Home
<br />® Other (SpecifYIASSISTED.LIVING
<br />9 Hospice Facility
<br />9b. COUNTY
<br />Hall
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CnY:LIMITS'
<br />® YES ❑ NO
<br />10a. MARITAL
<br />❑ Married.
<br />STATUS AT TIME OF DEATH ® Married 0 Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />but separated ❑ Widowed 0 Divorced 0 Unknown Dorothy Bruha
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Thomas Henry Meuret
<br />I' 12. MOTHER'S -NAME (First, Middle,
<br />Bridget Boyle
<br />Maiden Surname)
<br />13. EVER IN U.$,ARMED;FORCES? Give dates of service If Yes.
<br />(Yss, No, or UA.) No
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Re:newel 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Dorothy Meuret
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />6b. LICENSE NO.
<br />1092
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />October 14, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Ord City Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska
<br />CITY /TOWN
<br />Ord
<br />STATE
<br />Nebraska
<br />17b. zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />13. PART L Einar lilt chain prevents- -diseases. Injuries, or complications -that directly caused the death, DO NOT eniertatthinal *vents such as cardiac smith,
<br />talthrlitOfy arrest, Or ventrlcidar fibrillation without showing thea etiology. 00 NOT ABBREVIATE. Hater only one taus* 00 a tine. Add additional lines 6 necessary.
<br />IMMEDIATE CAUSE:
<br />6) Multisystem Organ Failure
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />Sequentially tlet conditfone. If
<br />any, loading to the cause lotted
<br />online a.
<br />Enter the UNDERLYING CAUSE
<br />ldiseue at INury that hddat.d
<br />the even rrsold np in death)
<br />LASTS
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Alzheimers Dementia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />onset to death
<br />onset to death
<br />18. PART II.OTHER SIGNIFIC
<br />ANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE'
<br />0 Not pregnant within put year
<br />❑ Pregnant n time of death
<br />❑ Net pregnant, Out prevent within 42 days of death
<br />0 Not pregnant, but pregnant 42 days to 1 year before death
<br />❑ Unknown H pnrsr.M wt yin the nest year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ 6ulcide 0 Count not be determined
<br />21b.IFTRANSPORTATION INJURY
<br />9 OriyeriOperator
<br />❑ Passenger
<br />9 Pedestrian
<br />0 Other:ISpkiry)
<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 />22d. INJURY AT WORK?
<br />❑YES 0NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO.
<br />re
<br />g
<br />231. DATE OF DEATH (Mo., Day, Yr.)
<br />October 8, 2019
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />October 10. 2019 08:19 AM
<br />23d. To the best of my knowledge, death occurred at the time, data and place
<br />and due to the causal') slated. (Signature and Title)
<br />Chad Vieth, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES to NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.i
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation. In my opinion death occurred M
<br />the time, data and place and due to the cause(s) stated (Signature and Tdle)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 1
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'$ SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 15, 2019
<br />
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