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<br />CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />UMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />I IS THE LEGAL DEPOSITORY FOR ::VITAL RECORDS
<br />DECEDENTS -NAME (First,
<br />Keith Evan Meyer
<br />RUSSELL FOSLOER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />ATE OF NEBRASKA- DEPARTMENT OF HEAI,TH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Last Suffix)
<br />2.8EX
<br />Mate
<br />& OATS OF DEATH (Mo., Day, W.)
<br />August 14, 2019
<br />Sa. AGE Last SIrthday.
<br />(Yrs )
<br />52
<br />DIAL SECURE
<br />04-042!
<br />N
<br />IBER
<br />SO. INREI
<br />YEAR
<br />8c. UNDER 1.DAY
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF MR
<br />September 24; #'966
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC
<br />.ERiDutpatlent ® Home
<br />0 Other (Specify)
<br />❑;D.
<br />CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand.Islet ...01 .., �.
<br />RESIDENCE -STATE:
<br />STREET AND NUMBER
<br />2824 S. Shady Bend Road
<br />Sb. COUNTY
<br />Hall
<br />I8d. COUNTY.OF DEATH
<br />i
<br />Hall r•
<br />9:c CITY OR TOWN....
<br />Grand tsfand'`
<br />le. APT. NO.
<br />St. TIP CODE
<br />68801
<br />9g. i1Sii1E erne LINTS
<br />❑ YES al NO
<br />MARITAL STAt1 AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated( 0 Widowed 0 Divorced 0 Unknown
<br />1. FATHER'S-RABE (first, Suffix)
<br />Yale August Meyer
<br />Middle, Last,
<br />10b. NAME OF SPOUSE (Ft : Middle, Last, Suffix) if wife, give maiden Wire.:
<br />Brenda Vtibbig
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />LaVera Schmidt
<br />&<: EVER IN U.& ARMED FORCES?
<br />es, No, or Unk.) NO
<br />Give dates of service If Yes.
<br />1S MIE:THODOF)tSPOSfT{(ON
<br />❑ BurEal ❑ Ootiatidxt
<br />151) Crdf
<br />on 0 Entombment
<br />[3.„.00M0101 :I] other
<br />(spade,)
<br />14a. INFORMANT -NAME .;.
<br />Brenda Meyer
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />14b. RELATIONSHIP TO OEC!..PENT ..;::;
<br />Spouse
<br />LICENSE NO.
<br />18s. DATE
<br />August 16, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Ta FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />PAttT1.
<br />CAUSE OF DEATH (See (nstruCtions:and examples)
<br />the' Of events —diseases, injuries, or complcationsUut directly caused the Eeath DO NOTantittin hN sxatts such as cardiac arrest,
<br />rtudn
<br />st, oryentdcuier tibriawetlon without showing the etiology. DO NOT ABBREVIATE. Enter only one CMOs on a Deo Add additional does If nor.
<br />IMMEDIATE CAUSE:
<br />*MEDIATE CAUSE (Final e) Spindle Cell Metastatic Sarcoma Lung And Hips
<br />disease or condgbn resulting
<br />DUE TO,fOR AS CONSEQUENCE OF:
<br />SethlOatiany ttst eoseitIoaa, l : i; ;;b)
<br />.:.
<br />any,leading to the cease aSied >"
<br />on line a. •
<br />Enter the UNDERLYING CAUSE
<br />ttjiseaseorrtylnyt erinittared
<br />tesuaing In death)
<br />•
<br />1Tb. ;:Dade.
<br />68$111
<br />APPRCXMATS
<br />• onset totkiiiM
<br />N/A
<br />onset OS
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given M PART I.
<br />20. IF;FMALE
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />Notpregnant. but pregnant: within 4Y deft of death
<br />Nat pregnant. b ut pregnant.4t days tel year before death
<br />l nkntlwlt
<br />If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide 0 Couidiot be determined
<br />22b. TIME OF INJURY
<br />Other(Specify)
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, oonstruceen sits, etc. (Specify)
<br />URY AT W
<br />.............OR........K?..
<br />NJ,
<br />:❑ YES ❑ NCi
<br />CITY/TOWN
<br />STATE
<br />XTH (Mo., Day, Yr.). <,
<br />2019
<br />tb fOI ACC Ct' HISS CO NTRIBUTE TO THE DEATH?
<br />YEs
<br />t NO ❑ PROBABLY ❑ UNKNOWN
<br />AME TITLE AND ADORERS OF CERTIFIER (Type or Print
<br />nda R ;;hurtle,.,: APRNINP-C, 1021 W 14th St., P.O. Box 968, Hastings, Nebraska, 68
<br />.re
<br />28b. DATE FILED BY REGISTRAR;Mp
<br />August 19, 2019
<br />
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