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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 OFISSUANCE
<br />12/9/2020
<br />LINCOLN, NEBRASKA
<br />202103366�SAR HBOHN NKAMP f
<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 />20 17497
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Barbara Ann Meyer
<br />2. SEX
<br />Female
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Fairbury, Nebraska
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />75
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo, Day, Yr.)I,
<br />November 13, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />7. SOCIAL SECURITY NUMBER
<br />508-56-2196
<br />8b: FACILITY -NAME Of not Institution, give street and number)
<br />207 W Syria Street
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Cairo 68824
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />207 W Syria Street
<br />9b. COUNTY
<br />Hall
<br />10a: MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Cairo
<br />July 22, 1945:.,
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9t. ZIP CODE
<br />68824
<br />Hospice Facility
<br />9g. INSIDE CtTY LIMITS
<br />DI YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) 0 wife, give maiden name
<br />Jerry Meyer
<br />11. FATHERS -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First,
<br />Irvin H Junker Marjorie E Glaze
<br />13. EVER 1N U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />14a. INFORMANT -NAME
<br />Jerry Meyer
<br />Middle, Malden Surname);
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />] Cremation 0 Entombment
<br />0 Removal ' 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />16e. DATE (Mo., Day, Yr.),
<br />November 14, 2020
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Horne, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801:
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Eller the chain of events- diseases, injuries, or compllcatione.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 line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Lung Cancer
<br />IMMEDIATE CAUSE (final
<br />disease or conpition MA' king
<br />In. death}
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on One a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Years
<br />onset to death
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Uterine Cancer
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?' '
<br />❑ YES ® NO
<br />20. IF FEMALE;
<br />❑'r Not pregnant within peat year
<br />Pregnantat dmf Of death
<br />©: Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown If pregnant wlMln the past year
<br />21a. MANNER OF DEATH
<br />Nature! 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide ❑ 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 AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />220. 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.ISpeci#y)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.'LOCATION 'OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />November 13, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 13, 2020
<br />23c. TIME OF DEATH
<br />06:19 AM
<br />23d. to distant of my knowledge, death occurred at the time, date and piece
<br />and due -Wee' cause(s) stated. (Signature and Title)
<br />Chad Vieth, MD
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion deaat occurned et
<br />the time, date and place and due to the cause(s) stated. (Signature and Tine)
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES NO '❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO < 0 YES'
<br />NO
<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'S SIGNATURE
<br />a -44 -A 8.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 9, 2020
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