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<br />HEN THIS ''COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />TIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />N FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />CORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />TE OF ISSUANCE
<br />......... ............
<br />9/27/2021
<br />COLN, NEBRASKA
<br />202109807
<br />' p7
<br />1-)1,0441.41.4.4
<br />)
<br />=+n
<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 />1. DE DENTS44AME (First, Middle, Last, Suffix)
<br />Alv n Edward Meyer
<br />4. CI D STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St. ichael, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />97
<br />7. SO SECURITY NUMBER
<br />50.28-1473
<br />a 8b. FA. LITY-NAME (if not Institution, give street and number)
<br />0
<br />d
<br />E
<br />Pri rose. Retirement of Grand Island
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />21 12162
<br />3. DATE OF DEATH (Mo.,:Day, Yr.)
<br />September 4, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 14, 1924
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />2 8c. CI OR TOWN OF DEATH (Include Zip Code)
<br />a Gra • Island 68803
<br />9 9a. RE DENCE-STATE
<br />g Ne • aska
<br />9d. 5 ET AND NUMBER
<br />399 t W. Capital Avenue
<br />OTHER ❑ Nursing Home/LTC
<br />0 Decedent's Home
<br />E Other (Specify)ASSISTED LIVING
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />10a. NI ITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />, ❑ rrled, but separated E Widowed 0 Divorced 0 Unknown
<br />e 11. FA ER'S-NAME (first, Middle, Last, Suffix)
<br />IHen Meyer
<br />0
<br />0
<br />9f. ZIP CODE
<br />68803
<br />9g INSIDE. CITYLiMITS
<br />YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />12. MOTHER'S -NAME (First,
<br />Dora Putscher
<br />Middle, Maiden Surname)
<br />13. EV = IN U.S.ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />15. ME OD OF DISPOSITION
<br />Tial [Donation
<br />0 C mationy 13 Entombment
<br />R oval 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Jayne Reimers
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />16b. LICENSE NO.
<br />1439
<br />14b. RELATIONSHIP TODECEDEKT:
<br />Daughter
<br />16c. DATE (Mo,, Day,. Yr.)....
<br />September 9;2021.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />17a. FU ERAL HOME. NAME AND MA LING ADDRESSJStreet, City or Town, State)
<br />Liv( Aston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART . Enter the chain of events. -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />res • atory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines a necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory failure
<br />IMMED TE CAUSE (final
<br />di se . oenditicn rebuking
<br />In death
<br />Sequa -- Ily list conditions, 6
<br />any, lea ng to the camas.linted
<br />on line
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Obstructive Pulmonary Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Emelt UNDE$LVINGCAusE c)
<br />(dine • r Injury that initiated
<br />the eve
<br />LAST
<br />"'suiting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18, PAR it. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Coro :fly artery disease, chronic kidney disease
<br />20.IF:F: ALE:
<br />0 Not . regnant within past year
<br />0 P time ofdeatti
<br />❑ Not . gnant, but Pregnant within 42 days of death
<br />0 Not • regnant, but pregnant 43 days to 1 year before death
<br />0 own U pregnant within the past year
<br />224. DA
<br />OF INJURY (Mo Day, Yr.)
<br />22d. INJ RY AT WORK?
<br />YES ❑ NO
<br />21a. MANNER OF DEATH
<br />ENatural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />< 1 Week
<br />onset to death
<br />> 1 Year
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES E NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta. (Spec(!
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LO • TIONOF INJURY' STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 4, 2021
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />September 15, 2021 01:40 o
<br />3d. To the Trost of my knowledge, death occurred at the time, date and place
<br />and due lefhe eause(s) stated. (Signature end Title)
<br />Jennifer L. Brown, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<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 deettOtCerred at
<br />the time, data and place and due to the causes) stated. (Signature **tome
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 0 0 YES El NO
<br />25. DID • BACCO USE CONTRIBUTE TO THE DEATH?
<br />NO 0 PROBABLY E UNKNOWN
<br />27. NAM , TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jen ifer L Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />L___3a-"Z
<br />28a. RE r ISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES
<br />❑ No
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 15, 2021
<br />
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