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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 />2/1/2021
<br />LINCOLN, NEBRASKA
<br />202102571
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />21 01161
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gary Francis Meyer
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />Found January 20, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />56
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 13, 1964,.;,,,
<br />7. SOCIAL SECURITY` NUMBER
<br />506.84-0027
<br />8b.°FACILITY•NAME (Snot Institution, give street and number)
<br />1221 W John Street
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9d. STREET AND NUMBER
<br />1221 W John Street
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS>
<br />O YES ❑ NO
<br />ice, MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated 0 Widowed ® Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Lynwood Francis Meyer
<br />112. MOTHER'S -NAME (First, Middle,
<br />Marian M Woestman
<br />Maiden Sumame)
<br />13. EVER IN LLS. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Jennifer Pokorney
<br />14b. RELATIONSHIP TO DECEDENT
<br />Sister
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />al Cremation 0 Entombment
<br />❑<Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.).
<br />January, 22, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Horne, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. 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,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a lino. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Unknown Natural Causes
<br />IMMEDIATE CAUSE (rine)
<br />disease er tonddien resulting
<br />M death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, loading to tie cause listed
<br />Enter tba:UNDERLYI
<br />(disease or Iniwythat
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />CAUSE C)
<br />vitiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART It. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />AlcOho( Use; Tobacco Use; Refusal To Seek Medical Treatment; Unsanitary Home Conditions
<br />17b. Zip Code
<br />68801;
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE:
<br />0 tint pregnant' within past, year
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />ElUnknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other(Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES J NO
<br />21d. WERE AUTOPSY FINDINGS AVAILAt l
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. 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 />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION;OFINJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />234. To the beat of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES 0 NO ]PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />January 22, 2021
<br />24b. TIME OF DEATH
<br />Approx. 09:00 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />January 20, 2021
<br />24d. TIME PRONOUNCED DEAD
<br />03:40 PM
<br />244, On the basis of examination andlor Investiga ion, In my opinion death occurred at
<br />Me time, date and place and due to the cause(s) stated (Signatureaunt Tme)
<br />S. Alex West, Hall Deputy County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable 1f 26a Is NO ❑ YES:
<br />❑NO;
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />S Atex West, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28b. DATE FILED BY REGISTRAR (Mo., D
<br />January 29, 2021
<br />ay, Yr.)28a. REGISTRAR'S SIGNATURE1
<br />
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