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STATE OF NEBRASKM DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Meddle. Last, Suffix)
<br />Carl John Meier
<br />0200. 9
<br />1
<br />II
<br />.
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH B5. AOE•N.ast Birthday lb.
<br />Petersburg, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-32-3498
<br />tib. FACILITY -LAME (tl not Institution, give street and number)
<br />Parsons House
<br />llo. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />Omaha 68164
<br />Ba. RESIDENCE -STATE
<br />Nebraska
<br />Id. STREET AND NUMBER
<br />3208 Kennedy Circle
<br />Mx COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Monad ❑ Never Married
<br />0 Marded, but.IParated 0 Widowed 0 DlvoreaN ❑ Unknown
<br />11. FATHER'S -NAME (Fat, Middle. Last, Suffix)
<br />Carl John Meier Sr
<br />13. EVER IN U.S. ARMED FORCES? Glee dates of service N Yes.
<br />(Yes, No, ot Ink.) No
<br />18. METHOD OF DISPOSITION
<br />®Seat ❑Den'00n
<br />❑ Oremellon ❑"
<br />❑Remonl ❑OtloABredtyl
<br />YEAR
<br />2. SEX
<br />Male
<br />Bo. UNDER 1 DAY
<br />(Yrs.) - MOS.
<br />78
<br />DAYS
<br />2& PLACE OF DEATH
<br />tttrel.L ❑ irthellent
<br />❑ EWOutpaUeat
<br />❑am
<br />Bt CnY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />333419
<br />3. DATE OF DEATH (Ma.,Day,Yr.)
<br />December 3, 2008
<br />I DATE OF BIRTH (Me., Day. Yr.)
<br />April 25, 1930
<br />maga RI Nursing HewarLTC
<br />❑ Decedent's Hems
<br />❑ otla(Eneray)
<br />ad. COUNTY OF DEATH
<br />Douglas
<br />Ne. APT. NO.
<br />W. EP CODE
<br />68803
<br />10b. NAME OF ePOUSE (Fiat, Biddle, Last, Suffix) S oda, glee maiden name.
<br />Loretta Rotherham
<br />14s. INFORMANT -NAME
<br />Loretta Meier
<br />ttia EMBALMER•SIONATURE
<br />❑ Hoapka Fawner
<br />12. MOTHER'S -NAME (fit, Middle, Malden Surname)
<br />Catherine Mary Schalk
<br />180. UCENS! NO.
<br />1326
<br />11Id. CEMETERY, CREMATORY OR OTHER LOCATION CRY/TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />INSIDE CITY UNITS
<br />® Yee ❑ No
<br />14b. RE A11ONSHIP TO DECEDENT
<br />Wife .
<br />18c. DAT! (Me, Dry, Yr.)
<br />December 6, 2008
<br />STATE
<br />Nebraska
<br />1
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />171. ZLp Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />te. PART I. Enter the yhela • dlrwes, allure.. or eomylkatlem- that dimity gond the death. DO NOT eater terminal orae seen ea aware anew,
<br />respiratory west, or remrketer Ser letlen wM1Yt.narring 2. Web's. DO NOT ABBRVAATE. Enter only one ears en ■ Ona. Add wkalleael Now B neawry.
<br />IMMEDIATE CAUSE:• �`�,
<br />IMMEDIATE CAUSE (Final
<br />Meath or condition resulting
<br />in death)
<br />Sequ.nNally Net conditions, N
<br />why, Madng to the cause Noted
<br />on line o.
<br />T
<br />DUEDUE /LS'
<br />TO, OR A CONSEQU!'
<br />b)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />r'
<br />rr�'Jr
<br />onset to death
<br />DUE TO, dit Ile A CONSEQUENCE OF:
<br />Enter 1M UNDERLYING CAUSE c)
<br />(dlseawe or Injury Ghat initiated DUE TO, OR AS AN7,ONSlr.Ot1
<br />the semi reading M death)
<br />LAST
<br />d)
<br />onset to death
<br />onset to death
<br />18. PART 0. OTHER SN;NIICANT CONDITIONS -Conditions contributing to the death but not mulling In the underlying cause given In PART L
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES eta
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant et time of death
<br />O Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />['Unknown N pregnant within the past year • •
<br />V
<br />r�
<br />22a DAT! OF INJURY (Mo., Day, Yr.)
<br />O
<br />F
<br />P
<br />215.//WANNER OF DEATH
<br />QNabral 0 Homicide
<br />o Accident 0 Panding Investigation
<br />o Suicide 0 Could not b. determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ OriverfOPwMot
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ OEur (SPeci►y)
<br />21c. WAS AN AUTOPSYpB1FORMlD?
<br />❑ YES •! NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑wo
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home. fano, street, rectuy, Dace building, construction site, eta (Specify)
<br />22d. INJURY AT WORK?
<br />ter] YES ❑ NO
<br />22e. DESCRIBE HDW INJURY OCCURRED
<br />22f. LOCATION OF INJURY . STREET 8 NUMBER, APT. NO.
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />23s. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Me., Day, Yr.)
<br />-/2-
<br />8f
<br />23c. TIME OF DEATH
<br />11:00
<br />22d.To .nd the
<br />totheof my
<br />knowledge,(Signature ath uand at
<br />the date
<br />.and place
<br />24.. DATE SIGNED (Mo.. Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />24c. PRONOUNCED DEAD (Mo, Dry, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24.. On the bawls of exanimtlon andlor Investigation, In ray opinion death occurred
<br />at the time; date and plume and due to the seat..(.) sated. (fie and Title)
<br />•
<br />TION BEEN CONSIDERED?
<br />m. DID TOBACCO SE CON UTE TO THE DEATH? 2Ba HAS ORGAN OR TISSUE D9HA
<br />0 YES �O ❑PROBABLY ❑UNKNOWN ❑ rS L-vJ✓
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S HYSICIIN OR COUNTY ATTORNEY) (Type or Print)
<br />NO
<br />22h. WAS CONSENT GRANTED?
<br />Not Applicable N the le NO 0 YES 0 NO
<br />O
<br />25a. REOISTRAMCs
<br />fa
<br />2Bb DATE FLED BY REGISTRAR (Mo., Dry, Yr.)
<br />DEC 1 8 2008
<br />This extifies tfijs document tt) be a true copy -of i original record on file with Vital Statistics, Douglas County
<br />H'earih lept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions
<br />of 1314is-,grebn.9ertificate atre not legal copies.
<br />Date Iss OEC' 1,, 8 anon
<br />Registrar:
<br />Aer&-
<br />
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