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059 480 to 1�1t1AltAlEgse�si..rrtaa I))d /II)iR4CrWJit Xzb99999Ai999dtya' as ytyigyAfl� r . rrR/499Ai(IMI,`a�"? WHEN 4 THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE ', A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 12/9/2020 LINCOLN, NEBRASKA 2O 2 0 0 9 8 2 474 SA` H BOHNENKAMPr ASSISTANT STATE REGISTRAR "< DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 20 17497 0 h ro E m 1. DECEDENT'S -NAME. (First, Middle, Last, Suffix) Barbara Ann Meyer 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fairbury, Nebraska 5a. AGE - Last Birthday (Yrs.) 75 Sb. UNDER 1 YEAR 2. SEX Female Sc. UNDER 1 DAY MOS. DAYS HOURS MINS. 3. DATE OF DEATH "(Mo, Day, Yr.) November 13, 2020 8. DATE OF BIRTH (Mo., Day, Yr.),! 7. SOCIAL SECURITY NUMBER 508-56-2196 8b. FACILITY -NAME of not Institution, give street and number) 207 W Syria Street 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/Outpatient ❑ DOA July 22,:1945 OTHER 0 Nursing Home/LTC ® Decedent's Home 0 Other (Specify) Sc. CITY OR TOWN OF DEATH (Include Zip Code) Cairo 68824 9a. RESIDENCE -STATE Nebraska Sb. COUNTY Hall 9c. CITY OR TOWN Cairo led. COUNTY OF DEATH Hall 9d. STREET AND NUMBER 207 W Syria Street Be. APT. NO. 9f. ZIP CODE 68824Ba 9g. INSIDE YES CITY LIMITS ❑ NO fOa, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Jerry Meyer 11, FATHER'S -NAME (First, Middle, Last, Suffix) Irvin H Junker 12. MOTHER'S -NAME (First, Middle, Marjorie E Glaze Maiden Surname) 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yea, No, or Unit.) No 14a. INFORMANT -NAME Jerry Meyer 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION 0 Burial ❑Donation 131 Cremation 0 Entombment Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) November 14, 2020 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 11I. 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, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Fina] a) Lung Cancer disease oreend tion reentries In death) DUE TO, OR AS A CONSEQUENCE OF: sequentially list conditions, if b) any, leading to the cause listed on fine a, APPROXIMATE INTERVAL onset to death Years onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or irqury that Initiated on to death< the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) 8. PART II.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. Uterine Cancer 20. IF FEMALE: 0 Net pregnant within past year 0 Pregnant at time of death v Not pregnant, but stagnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑: Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident ❑ Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 0 Pedestrian 0 Other (Specify) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO, 22a DATE OP INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f, LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN 23a. DATE OF DEATH (Mo., Day, Yr.) November 13, 2020 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH November 13, 2020 06:19 AM tad. To -:the hest of my knowledge, death occurred at the time, date and place and due to 11* cause(s) stated. (Signature and Tale) Chad Vieth, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? CI YES ® NO 0 PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH ZIP CODE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or Investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tale):: 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 28a. REGISTRAR'S SIGNATUREjok,4 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 9, 2020 0 0) C CD