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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL : I7~ CERTIFIES
<br />THE BELOW TO BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE= '�` s �( ' }'AND,
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY Fr)
<br />DATE OF ISSUANCE
<br />11/13/2014
<br />LINCOLN, NEBRASKA
<br />202109625
<br />•E CaOPER D� �'
<br />?ASST` S, AI9T STATE RE9I&_TRA-6*--.
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<br />DEORTMEN7129F-H �i�1 An%► ,+, !'
<br />H U 0141te SERW 1tBB,
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HOMAN SER)IpEti�
<br />CERTIFICATE OF DEATH`. - • �a 0$783
<br />Me fled by: FUNERAL DIRECTOR 1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />DeLysle Kenneth Meyers Jr
<br />2. , v '.,,�
<br />Ma ,:te _•
<br />TE .-
<br />10y, Yr.)
<br />J ,NQ,ve)nbi$r 1,:2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ba. AGE - Last Birthday
<br />Iib. UNDER 1 YEAR
<br />Sc. UNDER t dAY +
<br />8.,4TE OF IRTR (Mo., Day, Yr.)
<br />Holmesville, Nebraska
<br />(Yred
<br />86
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />-a
<br />September 19, 1928
<br />7. SOCIAL SECURITY NUMBER
<br />508-30-7077
<br />8a. PLACE OF DEATH
<br />HOSPITAL I@ Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />❑ DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />4349 Sherwood Rd.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) M wife, glMsimaid.n name
<br />Delores Ann Paneitz - -.0
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />DeLysle Meyers Sr
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Bertha Bowles • • -'
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service M Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Delores Ann Meyers
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />November 6, 2014
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Zion Evangelical Lutheran Cemetery Hampton Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stab)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />I
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />11. PART 1. Enter the Injuria, directly the death. DO NOT terminal '
<br />Shinn of events -diseases, or complications -tat caused enter swats such as cardiac anest,
<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 />IMMEDIATE CAUSE (Final a) Coffee Ground Emesis And Probable Gastrointestinal Bleed
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Hours
<br />In demi DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Sequentially ilat conditions, w b)Aortic Stenosis i Years
<br />any, leading to the cause listed I
<br />1
<br />kine
<br />on a DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />Enter the UNDERLYING CAUSE c)Atrial Fibrillation On Coumadin I Years
<br />(disease or injury that initiated .
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />LAST d) 1
<br />1
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Right THA, Diabetes, End Stage Renal Disease On Dialysis, Ileus
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES EI NO
<br />20. IF FEMALE:
<br />0 Not pregnant within put year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />o Not pregnane, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the pest year
<br />suicide Could not b. aatenniMd
<br />❑ ❑
<br />0 Pedestrian
<br />0 Other (SPscly)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, fano, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />DYES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />E
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 1, 2014
<br />L' s
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />0 Ei
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 11, 2014
<br />23c. TIME OF DEATH
<br />11:44 PM
<br />I 5
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />. To eat Pest of my knowtedge, death oeeurtM at tat three, date and plan
<br />E and dw to tat caueys) stated. ISgeawre and TSteI
<br />ui
<br />12 a Kimberly A. Mickels, MD
<br />"
<br />E
<br />` § S
<br />24e. On the basis of examination andlor Invesd
<br />the time, date and gsekt) Mand opinion death occurred at
<br />plan and due to the causes) stated. (Signature and ?tete)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR ' OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES El NO
<br />tab. WAS CONSENT GRANTED?
<br />Not Applicable H 28a 18 NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue,
<br />Grand Island, a, 68803
<br />28a. REGISTRAR'S SIGNATURE A- cave„,,,,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 12, 2014
<br />
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